|
IFR MEASUREMENT
|
Facility
|
IP
|
$1,860.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
48100101
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$558.00 |
| Max. Negotiated Rate |
$1,785.60 |
| Rate for Payer: Aetna Commercial |
$1,432.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,450.80
|
| Rate for Payer: Cash Price |
$930.00
|
| Rate for Payer: Cigna Commercial |
$1,543.80
|
| Rate for Payer: First Health Commercial |
$1,767.00
|
| Rate for Payer: Humana Commercial |
$1,581.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,525.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,372.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$558.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,636.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,395.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,618.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,283.40
|
| Rate for Payer: PHCS Commercial |
$1,785.60
|
| Rate for Payer: United Healthcare All Payer |
$1,636.80
|
|
|
IFR MEASUREMENT
|
Facility
|
OP
|
$1,860.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
48100101
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$1,785.60 |
| Rate for Payer: Aetna Commercial |
$1,432.20
|
| Rate for Payer: Anthem Medicaid |
$639.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,450.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$930.00
|
| Rate for Payer: Cash Price |
$930.00
|
| Rate for Payer: Cigna Commercial |
$1,543.80
|
| Rate for Payer: First Health Commercial |
$1,767.00
|
| Rate for Payer: Humana Commercial |
$1,581.00
|
| Rate for Payer: Humana KY Medicaid |
$639.65
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$646.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,525.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,372.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$652.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,636.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,395.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,618.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,283.40
|
| Rate for Payer: PHCS Commercial |
$1,785.60
|
| Rate for Payer: United Healthcare All Payer |
$1,636.80
|
|
|
IFR MEASUREMENT
|
Professional
|
Both
|
$1,860.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
48100101
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,302.00 |
| Rate for Payer: Cash Price |
$930.00
|
| Rate for Payer: Cash Price |
$930.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,116.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,302.00
|
| Rate for Payer: UHCCP Medicaid |
$651.00
|
|
|
IFR MEASUREMENT (P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
481P0101
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
|
IFR MEASUREMENT (T
|
Facility
|
OP
|
$1,660.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
481T0101
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$1,593.60 |
| Rate for Payer: Aetna Commercial |
$1,278.20
|
| Rate for Payer: Anthem Medicaid |
$570.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,294.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$830.00
|
| Rate for Payer: Cash Price |
$830.00
|
| Rate for Payer: Cigna Commercial |
$1,377.80
|
| Rate for Payer: First Health Commercial |
$1,577.00
|
| Rate for Payer: Humana Commercial |
$1,411.00
|
| Rate for Payer: Humana KY Medicaid |
$570.87
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$576.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,361.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,225.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$582.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,460.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,245.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,328.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,145.40
|
| Rate for Payer: PHCS Commercial |
$1,593.60
|
| Rate for Payer: United Healthcare All Payer |
$1,460.80
|
|
|
IFR MEASUREMENT (T
|
Facility
|
IP
|
$1,660.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
481T0101
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$498.00 |
| Max. Negotiated Rate |
$1,593.60 |
| Rate for Payer: Aetna Commercial |
$1,278.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,294.80
|
| Rate for Payer: Cash Price |
$830.00
|
| Rate for Payer: Cigna Commercial |
$1,377.80
|
| Rate for Payer: First Health Commercial |
$1,577.00
|
| Rate for Payer: Humana Commercial |
$1,411.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,361.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,225.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$498.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,460.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,245.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,328.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,145.40
|
| Rate for Payer: PHCS Commercial |
$1,593.60
|
| Rate for Payer: United Healthcare All Payer |
$1,460.80
|
|
|
IIV3 VACC NO PRSV 0.25 ML IM
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 90655
|
| Hospital Charge Code |
77000019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
IIV3 VACC NO PRSV 0.25 ML IM
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 90655
|
| Hospital Charge Code |
77000019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$31.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$31.98
|
| Rate for Payer: Kentucky WC Medicaid |
$32.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
IIV3 VACC NO PRSV 0.25 ML IM
|
Professional
|
Both
|
$93.00
|
|
|
Service Code
|
HCPCS 90655
|
| Hospital Charge Code |
77000019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Anthem Medicaid |
$18.40
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Humana Medicaid |
$18.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$56.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.77
|
| Rate for Payer: Molina Healthcare Passport |
$18.40
|
| Rate for Payer: Multiplan PHCS |
$55.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$65.10
|
| Rate for Payer: UHCCP Medicaid |
$32.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.58
|
|
|
IIV3 VACC NO PRSV 0.25 ML I(T
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 90655
|
| Hospital Charge Code |
770T0019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$31.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$31.98
|
| Rate for Payer: Kentucky WC Medicaid |
$32.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
IIV3 VACC NO PRSV 0.25 ML I(T
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 90655
|
| Hospital Charge Code |
770T0019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
77000034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
77000034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$46.90 |
| Rate for Payer: Anthem Medicaid |
$20.88
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$20.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.30
|
| Rate for Payer: Molina Healthcare Passport |
$20.88
|
| Rate for Payer: Multiplan PHCS |
$40.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.90
|
| Rate for Payer: UHCCP Medicaid |
$23.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.09
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
77000034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$23.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$23.04
|
| Rate for Payer: Kentucky WC Medicaid |
$23.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM(T
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
770T0034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM(T
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
770T0034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$23.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$23.04
|
| Rate for Payer: Kentucky WC Medicaid |
$23.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACC NO PRSV 0.25 ML IM
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
77000032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Anthem Medicaid |
$23.23
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$23.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$31.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$23.69
|
| Rate for Payer: Molina Healthcare Passport |
$23.23
|
| Rate for Payer: Multiplan PHCS |
$45.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$53.20
|
| Rate for Payer: UHCCP Medicaid |
$26.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$23.46
|
|
|
IIV4 VACC NO PRSV 0.25 ML IM
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
77000032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem Medicaid |
$26.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Humana KY Medicaid |
$26.14
|
| Rate for Payer: Kentucky WC Medicaid |
$26.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.44
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV4 VACC NO PRSV 0.25 ML IM
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
77000032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.44
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV4 VACC NO PRSV 0.25 ML I(T
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
770T0032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.44
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV4 VACC NO PRSV 0.25 ML I(T
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
770T0032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem Medicaid |
$26.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Humana KY Medicaid |
$26.14
|
| Rate for Payer: Kentucky WC Medicaid |
$26.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.44
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV NO PRSV INCREASED AG IM
|
Professional
|
Both
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
77000024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$108.60 |
| Rate for Payer: Ambetter Exchange |
$83.49
|
| Rate for Payer: Anthem Medicaid |
$83.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$83.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$83.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$100.19
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$83.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$83.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.16
|
| Rate for Payer: Molina Healthcare Passport |
$83.49
|
| Rate for Payer: Multiplan PHCS |
$108.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$108.54
|
| Rate for Payer: UHCCP Medicaid |
$63.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$83.49
|
|
|
IIV NO PRSV INCREASED AG IM
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
77000024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem Medicaid |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Humana KY Medicaid |
$62.25
|
| Rate for Payer: Kentucky WC Medicaid |
$62.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
IIV NO PRSV INCREASED AG IM
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
77000024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
IIV NO PRSV INCREASED AG IM(T
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
770T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
