|
IMMUNE ADMIN ORAL/NASAL ADDL
|
Professional
|
Both
|
$29.23
|
|
|
Service Code
|
HCPCS 90474
|
| Hospital Charge Code |
77000008
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$17.54 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Ambetter Exchange |
$11.08
|
| Rate for Payer: Anthem Medicaid |
$11.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$11.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$11.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.30
|
| Rate for Payer: Cash Price |
$14.62
|
| Rate for Payer: Cash Price |
$14.62
|
| Rate for Payer: Cigna Commercial |
$14.56
|
| Rate for Payer: Healthspan PPO |
$10.63
|
| Rate for Payer: Humana Medicaid |
$11.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$11.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.20
|
| Rate for Payer: Molina Healthcare Passport |
$11.96
|
| Rate for Payer: Multiplan PHCS |
$17.54
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.40
|
| Rate for Payer: UHCCP Medicaid |
$10.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$11.08
|
|
|
IMMUNE ADMIN ORAL/NASAL ADDL
|
Facility
|
OP
|
$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 Medicaid |
$10.05
|
| 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: Humana KY Medicaid |
$10.05
|
| Rate for Payer: Kentucky WC Medicaid |
$10.15
|
| 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: Molina Healthcare Medicaid |
$10.25
|
| 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
|
|
|
IMMUNOASSAY FOR ANALYTE
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
30000375
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$161.28 |
| Rate for Payer: Aetna Commercial |
$129.36
|
| Rate for Payer: Anthem Medicaid |
$11.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.53
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$139.44
|
| Rate for Payer: First Health Commercial |
$159.60
|
| Rate for Payer: Humana Commercial |
$142.80
|
| Rate for Payer: Humana KY Medicaid |
$11.53
|
| Rate for Payer: Humana Medicare Advantage |
$11.53
|
| Rate for Payer: Kentucky WC Medicaid |
$11.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$123.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$147.84
|
| Rate for Payer: Ohio Health Group HMO |
$126.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$134.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.92
|
| Rate for Payer: PHCS Commercial |
$161.28
|
| Rate for Payer: United Healthcare All Payer |
$147.84
|
|
|
IMMUNOASSAY FOR ANALYTE
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
30000375
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$161.28 |
| Rate for Payer: Aetna Commercial |
$129.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.90
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$139.44
|
| Rate for Payer: First Health Commercial |
$159.60
|
| Rate for Payer: Humana Commercial |
$142.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$123.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$147.84
|
| Rate for Payer: Ohio Health Group HMO |
$126.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$134.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.92
|
| Rate for Payer: PHCS Commercial |
$161.28
|
| Rate for Payer: United Healthcare All Payer |
$147.84
|
|
|
IMMUNOHISTO ANTB ADDL SLIDE
|
Facility
|
OP
|
$430.00
|
|
|
Service Code
|
HCPCS 88341
|
| Hospital Charge Code |
30001524
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$129.00 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem Medicaid |
$147.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$345.29
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Humana KY Medicaid |
$147.88
|
| Rate for Payer: Kentucky WC Medicaid |
$149.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.70
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
IMMUNOHISTO ANTB ADDL SLIDE
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
HCPCS 88341
|
| Hospital Charge Code |
30001524
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$129.00 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$345.29
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.70
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
IMMUNOHISTO ANTB ADDL SLIDE
|
Professional
|
Both
|
$430.00
|
|
|
Service Code
|
HCPCS 88341
|
| Hospital Charge Code |
30001524
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$258.00 |
| Rate for Payer: Ambetter Exchange |
$86.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$86.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$86.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$104.17
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$45.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$86.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.81
|
| Rate for Payer: Multiplan PHCS |
$258.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.85
|
| Rate for Payer: UHCCP Medicaid |
$150.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$30.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$86.81
|
|
|
IMMUNOLOGICAL ID AND TYPING
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS 87147
|
| Hospital Charge Code |
30001285
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$40.32 |
| Rate for Payer: Aetna Commercial |
$32.34
|
| Rate for Payer: Anthem Medicaid |
$5.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.18
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$34.86
|
| Rate for Payer: First Health Commercial |
$39.90
|
| Rate for Payer: Humana Commercial |
$35.70
|
| Rate for Payer: Humana KY Medicaid |
$5.18
|
| Rate for Payer: Humana Medicare Advantage |
$5.18
|
| Rate for Payer: Kentucky WC Medicaid |
$5.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$36.96
|
| Rate for Payer: Ohio Health Group HMO |
$31.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.98
|
| Rate for Payer: PHCS Commercial |
$40.32
|
| Rate for Payer: United Healthcare All Payer |
$36.96
|
|
|
IMMUNOLOGICAL ID AND TYPING
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS 87147
|
| Hospital Charge Code |
30001285
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$40.32 |
| Rate for Payer: Aetna Commercial |
$32.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.73
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$34.86
|
| Rate for Payer: First Health Commercial |
$39.90
|
| Rate for Payer: Humana Commercial |
$35.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$36.96
|
| Rate for Payer: Ohio Health Group HMO |
$31.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.98
|
| Rate for Payer: PHCS Commercial |
$40.32
|
| Rate for Payer: United Healthcare All Payer |
$36.96
|
|
|
IMMUNOTHERAPY 2 OR MORE INJEC
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 95125
|
| Hospital Charge Code |
94000010
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
IMMUNOTHERAPY 2 OR MORE INJEC
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 95125
|
| Hospital Charge Code |
94000010
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$30.52 |
| Rate for Payer: Aetna Commercial |
$20.39
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$30.52
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.78
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
|
|
IMMUNOTHERAPY 2 OR MORE INJEC
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 95125
|
| Hospital Charge Code |
94000010
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$13.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Humana KY Medicaid |
$13.76
|
| Rate for Payer: Kentucky WC Medicaid |
$13.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
IMMUNOTHERAPY 2 OR MORE INJE(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 95125
|
| Hospital Charge Code |
940P0010
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$30.52 |
| Rate for Payer: Aetna Commercial |
$20.39
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$30.52
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.78
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
|
|
IMMUNOTHERAPY SINGLE INJECTION
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS 95120
|
| Hospital Charge Code |
940T0009
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
IMMUNOTHERAPY SINGLE INJECTION
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
HCPCS 95120
|
| Hospital Charge Code |
94000009
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$69.00 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem Medicaid |
$79.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$179.40
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Humana KY Medicaid |
$79.10
|
| Rate for Payer: Kentucky WC Medicaid |
$79.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.70
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
IMMUNOTHERAPY SINGLE INJECTION
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 95120
|
| Hospital Charge Code |
940P0009
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$25.43 |
| Rate for Payer: Aetna Commercial |
$16.04
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$25.43
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$23.75
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
IMMUNOTHERAPY SINGLE INJECTION
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
HCPCS 95120
|
| Hospital Charge Code |
94000009
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$69.00 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$179.40
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.70
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
IMMUNOTHERAPY SINGLE INJECTION
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS 95120
|
| Hospital Charge Code |
940T0009
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem Medicaid |
$68.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Humana KY Medicaid |
$68.78
|
| Rate for Payer: Kentucky WC Medicaid |
$69.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
IMMUNOTHERAPY SINGLE INJECTION
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 95120
|
| Hospital Charge Code |
94000009
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$16.04
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$25.43
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$23.75
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.00
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
|
|
IMODIUM A-D 1MG/7.5ML LIQUID
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 46122054426
|
| Hospital Charge Code |
25000774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
IMODIUM A-D 1MG/7.5ML LIQUID
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
NDC 46122054426
|
| Hospital Charge Code |
25000774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
IMODIUM (LOPERAMIDE) 2MG/1CAP
|
Facility
|
IP
|
$5.05
|
|
|
Service Code
|
NDC 60687022901
|
| Hospital Charge Code |
25000773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.19
|
| Rate for Payer: First Health Commercial |
$4.80
|
| Rate for Payer: Humana Commercial |
$4.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.85
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
IMODIUM (LOPERAMIDE) 2MG/1CAP
|
Facility
|
OP
|
$5.05
|
|
|
Service Code
|
NDC 60687022901
|
| Hospital Charge Code |
25000773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.19
|
| Rate for Payer: First Health Commercial |
$4.80
|
| Rate for Payer: Humana Commercial |
$4.29
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.85
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
IMPACT PEPTIDE 1.5 250mL BTL
|
Facility
|
IP
|
$72.86
|
|
|
Service Code
|
HCPCS B4153
|
| Hospital Charge Code |
27000288
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$69.95 |
| Rate for Payer: Aetna Commercial |
$56.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Cash Price |
$36.43
|
| Rate for Payer: Cigna Commercial |
$60.47
|
| Rate for Payer: First Health Commercial |
$69.22
|
| Rate for Payer: Humana Commercial |
$61.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.12
|
| Rate for Payer: Ohio Health Group HMO |
$54.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.27
|
| Rate for Payer: PHCS Commercial |
$69.95
|
| Rate for Payer: United Healthcare All Payer |
$64.12
|
|
|
IMPACT PEPTIDE 1.5 250mL BTL
|
Facility
|
OP
|
$72.86
|
|
|
Service Code
|
HCPCS B4153
|
| Hospital Charge Code |
27000288
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$69.95 |
| Rate for Payer: Aetna Commercial |
$56.10
|
| Rate for Payer: Anthem Medicaid |
$25.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Cash Price |
$36.43
|
| Rate for Payer: Cigna Commercial |
$60.47
|
| Rate for Payer: First Health Commercial |
$69.22
|
| Rate for Payer: Humana Commercial |
$61.93
|
| Rate for Payer: Humana KY Medicaid |
$25.06
|
| Rate for Payer: Kentucky WC Medicaid |
$25.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.12
|
| Rate for Payer: Ohio Health Group HMO |
$54.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.27
|
| Rate for Payer: PHCS Commercial |
$69.95
|
| Rate for Payer: United Healthcare All Payer |
$64.12
|
|
