|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
63600063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
636T0063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
636T0063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
63600063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$83.50 |
| Rate for Payer: Aetna Commercial |
$82.40
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Healthspan PPO |
$83.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.58
|
| Rate for Payer: Multiplan PHCS |
$70.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.60
|
| Rate for Payer: UHCCP Medicaid |
$41.30
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
25002378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
25002378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
63600063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMJUDO 1mg (25 mgSDV)
|
Facility
|
OP
|
$18,428.09
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$17,690.97 |
| Rate for Payer: Aetna Commercial |
$14,189.63
|
| Rate for Payer: Anthem Medicaid |
$6,337.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$141.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,373.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$197.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$190.58
|
| Rate for Payer: Cash Price |
$9,214.04
|
| Rate for Payer: Cash Price |
$9,214.04
|
| Rate for Payer: Cigna Commercial |
$15,295.31
|
| Rate for Payer: First Health Commercial |
$17,506.69
|
| Rate for Payer: Humana Commercial |
$15,663.88
|
| Rate for Payer: Humana KY Medicaid |
$6,337.42
|
| Rate for Payer: Humana Medicare Advantage |
$141.17
|
| Rate for Payer: Kentucky WC Medicaid |
$6,401.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,111.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,599.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,464.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,216.72
|
| Rate for Payer: Ohio Health Group HMO |
$13,821.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,742.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,032.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,715.38
|
| Rate for Payer: PHCS Commercial |
$17,690.97
|
| Rate for Payer: United Healthcare All Payer |
$16,216.72
|
|
|
IMJUDO 1mg (25 mgSDV)
|
Facility
|
IP
|
$18,428.09
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,528.43 |
| Max. Negotiated Rate |
$17,690.97 |
| Rate for Payer: Aetna Commercial |
$14,189.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,373.91
|
| Rate for Payer: Cash Price |
$9,214.04
|
| Rate for Payer: Cigna Commercial |
$15,295.31
|
| Rate for Payer: First Health Commercial |
$17,506.69
|
| Rate for Payer: Humana Commercial |
$15,663.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,111.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,599.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,528.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,216.72
|
| Rate for Payer: Ohio Health Group HMO |
$13,821.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,742.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,032.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,715.38
|
| Rate for Payer: PHCS Commercial |
$17,690.97
|
| Rate for Payer: United Healthcare All Payer |
$16,216.72
|
|
|
IMJUDO 1mg (300 mgSDV)
|
Facility
|
IP
|
$221,137.02
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66,341.11 |
| Max. Negotiated Rate |
$212,291.54 |
| Rate for Payer: Aetna Commercial |
$170,275.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$172,486.88
|
| Rate for Payer: Cash Price |
$110,568.51
|
| Rate for Payer: Cigna Commercial |
$183,543.73
|
| Rate for Payer: First Health Commercial |
$210,080.17
|
| Rate for Payer: Humana Commercial |
$187,966.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$181,332.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163,199.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66,341.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$194,600.58
|
| Rate for Payer: Ohio Health Group HMO |
$165,852.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176,909.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192,389.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152,584.54
|
| Rate for Payer: PHCS Commercial |
$212,291.54
|
| Rate for Payer: United Healthcare All Payer |
$194,600.58
|
|
|
IMJUDO 1mg (300 mgSDV)
|
Facility
|
OP
|
$221,137.02
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$212,291.54 |
| Rate for Payer: Aetna Commercial |
$170,275.51
|
| Rate for Payer: Anthem Medicaid |
$76,049.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$141.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$172,486.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$197.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$190.58
|
| Rate for Payer: Cash Price |
$110,568.51
|
| Rate for Payer: Cash Price |
$110,568.51
|
| Rate for Payer: Cigna Commercial |
$183,543.73
|
| Rate for Payer: First Health Commercial |
$210,080.17
|
| Rate for Payer: Humana Commercial |
$187,966.47
|
| Rate for Payer: Humana KY Medicaid |
$76,049.02
|
| Rate for Payer: Humana Medicare Advantage |
$141.17
|
| Rate for Payer: Kentucky WC Medicaid |
$76,823.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$181,332.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163,199.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$77,574.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$194,600.58
|
| Rate for Payer: Ohio Health Group HMO |
$165,852.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176,909.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192,389.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152,584.54
|
| Rate for Payer: PHCS Commercial |
$212,291.54
|
| Rate for Payer: United Healthcare All Payer |
$194,600.58
|
|
|
IMLYGIC 10^6 PFU ML VIAL (1ML)
|
Facility
|
IP
|
$380.79
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.24 |
| Max. Negotiated Rate |
$365.56 |
| Rate for Payer: Aetna Commercial |
$293.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.02
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cigna Commercial |
$316.06
|
| Rate for Payer: First Health Commercial |
$361.75
|
| Rate for Payer: Humana Commercial |
$323.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$312.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$335.10
|
| Rate for Payer: Ohio Health Group HMO |
$285.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$331.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.75
|
| Rate for Payer: PHCS Commercial |
$365.56
|
| Rate for Payer: United Healthcare All Payer |
$335.10
|
|
|
IMLYGIC 10^6 PFU ML VIAL (1ML)
|
Facility
|
OP
|
$380.79
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.55 |
| Max. Negotiated Rate |
$365.56 |
| Rate for Payer: Aetna Commercial |
$293.21
|
| Rate for Payer: Anthem Medicaid |
$130.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$73.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$102.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$99.29
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cigna Commercial |
$316.06
|
| Rate for Payer: First Health Commercial |
$361.75
|
| Rate for Payer: Humana Commercial |
$323.67
|
| Rate for Payer: Humana KY Medicaid |
$130.95
|
| Rate for Payer: Humana Medicare Advantage |
$73.55
|
| Rate for Payer: Kentucky WC Medicaid |
$132.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$312.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$133.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$335.10
|
| Rate for Payer: Ohio Health Group HMO |
$285.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$331.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.75
|
| Rate for Payer: PHCS Commercial |
$365.56
|
| Rate for Payer: United Healthcare All Payer |
$335.10
|
|
|
IMLYGIC 10^8 PFU ML VIAL (1ML)
|
Facility
|
IP
|
$38,072.56
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,421.77 |
| Max. Negotiated Rate |
$36,549.66 |
| Rate for Payer: Aetna Commercial |
$29,315.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,696.60
|
| Rate for Payer: Cash Price |
$19,036.28
|
| Rate for Payer: Cigna Commercial |
$31,600.22
|
| Rate for Payer: First Health Commercial |
$36,168.93
|
| Rate for Payer: Humana Commercial |
$32,361.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,219.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,097.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,421.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,503.85
|
| Rate for Payer: Ohio Health Group HMO |
$28,554.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30,458.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33,123.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26,270.07
|
| Rate for Payer: PHCS Commercial |
$36,549.66
|
| Rate for Payer: United Healthcare All Payer |
$33,503.85
|
|
|
IMLYGIC 10^8 PFU ML VIAL (1ML)
|
Facility
|
OP
|
$38,072.56
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.55 |
| Max. Negotiated Rate |
$36,549.66 |
| Rate for Payer: Aetna Commercial |
$29,315.87
|
| Rate for Payer: Anthem Medicaid |
$13,093.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$73.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,696.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$102.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$99.29
|
| Rate for Payer: Cash Price |
$19,036.28
|
| Rate for Payer: Cash Price |
$19,036.28
|
| Rate for Payer: Cigna Commercial |
$31,600.22
|
| Rate for Payer: First Health Commercial |
$36,168.93
|
| Rate for Payer: Humana Commercial |
$32,361.68
|
| Rate for Payer: Humana KY Medicaid |
$13,093.15
|
| Rate for Payer: Humana Medicare Advantage |
$73.55
|
| Rate for Payer: Kentucky WC Medicaid |
$13,226.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,219.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,097.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,355.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,503.85
|
| Rate for Payer: Ohio Health Group HMO |
$28,554.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30,458.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33,123.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26,270.07
|
| Rate for Payer: PHCS Commercial |
$36,549.66
|
| Rate for Payer: United Healthcare All Payer |
$33,503.85
|
|
|
IMME. INSERT OF BREAST PROSTHE
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19340
|
| Hospital Charge Code |
76100311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$687.80 |
| Max. Negotiated Rate |
$8,435.98 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,025.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,435.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,134.69
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Humana Medicare Advantage |
$6,025.70
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
IMME. INSERT OF BREAST PROSTHE
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19340
|
| Hospital Charge Code |
76100311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$453.06 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$600.32
|
| Rate for Payer: Ambetter Exchange |
$718.67
|
| Rate for Payer: Anthem Medicaid |
$453.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$718.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$718.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$862.40
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$564.71
|
| Rate for Payer: Healthspan PPO |
$480.01
|
| Rate for Payer: Humana Medicaid |
$453.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,125.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$718.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$718.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.12
|
| Rate for Payer: Molina Healthcare Passport |
$453.06
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$934.27
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$457.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$718.67
|
|
|
IMME. INSERT OF BREAST PROSTHE
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19340
|
| Hospital Charge Code |
761P0311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$453.06 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$600.32
|
| Rate for Payer: Ambetter Exchange |
$718.67
|
| Rate for Payer: Anthem Medicaid |
$453.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$718.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$718.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$862.40
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$564.71
|
| Rate for Payer: Healthspan PPO |
$480.01
|
| Rate for Payer: Humana Medicaid |
$453.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,125.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$718.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$718.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.12
|
| Rate for Payer: Molina Healthcare Passport |
$453.06
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$934.27
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$457.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$718.67
|
|
|
IMME. INSERT OF BREAST PROSTHE
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19340
|
| Hospital Charge Code |
76100311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
IMMUN ADM NASAL/ORAL
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
77000003
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$16.85 |
| Max. Negotiated Rate |
$92.06 |
| Rate for Payer: Aetna Commercial |
$37.73
|
| Rate for Payer: Anthem Medicaid |
$16.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$38.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.78
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$40.67
|
| Rate for Payer: First Health Commercial |
$46.55
|
| Rate for Payer: Humana Commercial |
$41.65
|
| Rate for Payer: Humana KY Medicaid |
$16.85
|
| Rate for Payer: Humana Medicare Advantage |
$65.76
|
| Rate for Payer: Kentucky WC Medicaid |
$17.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$40.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$43.12
|
| Rate for Payer: Ohio Health Group HMO |
$36.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.81
|
| Rate for Payer: PHCS Commercial |
$47.04
|
| Rate for Payer: United Healthcare All Payer |
$43.12
|
|
|
IMMUN ADM NASAL/ORAL
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
77000003
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$29.40 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Ambetter Exchange |
$15.26
|
| Rate for Payer: Anthem Medicaid |
$27.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$15.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$15.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.31
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: Healthspan PPO |
$15.91
|
| Rate for Payer: Humana Medicaid |
$27.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$15.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.04
|
| Rate for Payer: Molina Healthcare Passport |
$27.49
|
| Rate for Payer: Multiplan PHCS |
$29.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$19.84
|
| Rate for Payer: UHCCP Medicaid |
$17.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$15.26
|
|
|
IMMUN ADM NASAL/ORAL
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
77000003
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$47.04 |
| Rate for Payer: Aetna Commercial |
$37.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$38.22
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$40.67
|
| Rate for Payer: First Health Commercial |
$46.55
|
| Rate for Payer: Humana Commercial |
$41.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$40.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$43.12
|
| Rate for Payer: Ohio Health Group HMO |
$36.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.81
|
| Rate for Payer: PHCS Commercial |
$47.04
|
| Rate for Payer: United Healthcare All Payer |
$43.12
|
|
|
IMMUN ADM NASAL/ORAL(T
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
770T0003
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$16.85 |
| Max. Negotiated Rate |
$92.06 |
| Rate for Payer: Aetna Commercial |
$37.73
|
| Rate for Payer: Anthem Medicaid |
$16.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$38.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.78
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$40.67
|
| Rate for Payer: First Health Commercial |
$46.55
|
| Rate for Payer: Humana Commercial |
$41.65
|
| Rate for Payer: Humana KY Medicaid |
$16.85
|
| Rate for Payer: Humana Medicare Advantage |
$65.76
|
| Rate for Payer: Kentucky WC Medicaid |
$17.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$40.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$43.12
|
| Rate for Payer: Ohio Health Group HMO |
$36.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.81
|
| Rate for Payer: PHCS Commercial |
$47.04
|
| Rate for Payer: United Healthcare All Payer |
$43.12
|
|
|
IMMUN ADM NASAL/ORAL(T
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 90473
|
| Hospital Charge Code |
770T0003
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$47.04 |
| Rate for Payer: Aetna Commercial |
$37.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$38.22
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$40.67
|
| Rate for Payer: First Health Commercial |
$46.55
|
| Rate for Payer: Humana Commercial |
$41.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$40.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$43.12
|
| Rate for Payer: Ohio Health Group HMO |
$36.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.81
|
| Rate for Payer: PHCS Commercial |
$47.04
|
| Rate for Payer: United Healthcare All Payer |
$43.12
|
|
|
IMMUNE ADMIN ORAL/NASAL ADDL
|
Facility
|
IP
|
$29.23
|
|
|
Service Code
|
HCPCS 90474
|
| Hospital Charge Code |
77000008
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$28.06 |
| Rate for Payer: Aetna Commercial |
$22.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.80
|
| Rate for Payer: Cash Price |
$14.62
|
| Rate for Payer: Cigna Commercial |
$24.26
|
| Rate for Payer: First Health Commercial |
$27.77
|
| Rate for Payer: Humana Commercial |
$24.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.72
|
| Rate for Payer: Ohio Health Group HMO |
$21.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.17
|
| Rate for Payer: PHCS Commercial |
$28.06
|
| Rate for Payer: United Healthcare All Payer |
$25.72
|
|
