|
INFLIXIMAB 10MG (100MG)
|
Facility
|
IP
|
$6,364.62
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
25002160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,909.39 |
| Max. Negotiated Rate |
$6,110.04 |
| Rate for Payer: Aetna Commercial |
$4,900.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,964.40
|
| Rate for Payer: Cash Price |
$3,182.31
|
| Rate for Payer: Cigna Commercial |
$5,282.63
|
| Rate for Payer: First Health Commercial |
$6,046.39
|
| Rate for Payer: Humana Commercial |
$5,409.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,218.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,697.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,909.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,600.87
|
| Rate for Payer: Ohio Health Group HMO |
$4,773.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,091.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,537.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,391.59
|
| Rate for Payer: PHCS Commercial |
$6,110.04
|
| Rate for Payer: United Healthcare All Payer |
$5,600.87
|
|
|
INFLIXIMAB 10MG (100MG)
|
Facility
|
OP
|
$6,364.62
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
25002160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.18 |
| Max. Negotiated Rate |
$6,110.04 |
| Rate for Payer: Aetna Commercial |
$4,900.76
|
| Rate for Payer: Anthem Medicaid |
$2,188.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$31.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,964.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$43.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.09
|
| Rate for Payer: Cash Price |
$3,182.31
|
| Rate for Payer: Cash Price |
$3,182.31
|
| Rate for Payer: Cigna Commercial |
$5,282.63
|
| Rate for Payer: First Health Commercial |
$6,046.39
|
| Rate for Payer: Humana Commercial |
$5,409.93
|
| Rate for Payer: Humana KY Medicaid |
$2,188.79
|
| Rate for Payer: Humana Medicare Advantage |
$31.18
|
| Rate for Payer: Kentucky WC Medicaid |
$2,211.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,218.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,697.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,232.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,600.87
|
| Rate for Payer: Ohio Health Group HMO |
$4,773.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,091.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,537.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,391.59
|
| Rate for Payer: PHCS Commercial |
$6,110.04
|
| Rate for Payer: United Healthcare All Payer |
$5,600.87
|
|
|
inFLIXimab-AXXQ 100mg VIAL
|
Facility
|
IP
|
$2,725.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
25004020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$817.50 |
| Max. Negotiated Rate |
$2,616.00 |
| Rate for Payer: Aetna Commercial |
$2,098.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,125.50
|
| Rate for Payer: Cash Price |
$1,362.50
|
| Rate for Payer: Cigna Commercial |
$2,261.75
|
| Rate for Payer: First Health Commercial |
$2,588.75
|
| Rate for Payer: Humana Commercial |
$2,316.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,234.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$817.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,043.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,370.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,880.25
|
| Rate for Payer: PHCS Commercial |
$2,616.00
|
| Rate for Payer: United Healthcare All Payer |
$2,398.00
|
|
|
inFLIXimab-AXXQ 100mg VIAL
|
Facility
|
OP
|
$2,725.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
25004020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.89 |
| Max. Negotiated Rate |
$2,616.00 |
| Rate for Payer: Aetna Commercial |
$2,098.25
|
| Rate for Payer: Anthem Medicaid |
$937.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,125.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.20
|
| Rate for Payer: Cash Price |
$1,362.50
|
| Rate for Payer: Cash Price |
$1,362.50
|
| Rate for Payer: Cigna Commercial |
$2,261.75
|
| Rate for Payer: First Health Commercial |
$2,588.75
|
| Rate for Payer: Humana Commercial |
$2,316.25
|
| Rate for Payer: Humana KY Medicaid |
$937.13
|
| Rate for Payer: Humana Medicare Advantage |
$20.89
|
| Rate for Payer: Kentucky WC Medicaid |
$946.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,234.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$955.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,043.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,370.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,880.25
|
| Rate for Payer: PHCS Commercial |
$2,616.00
|
| Rate for Payer: United Healthcare All Payer |
$2,398.00
|
|
|
INFLUENZA A&B PCR
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
30001372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.70 |
| Max. Negotiated Rate |
$258.24 |
| Rate for Payer: Aetna Commercial |
$207.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.01
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: First Health Commercial |
$255.55
|
| Rate for Payer: Humana Commercial |
$228.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$220.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$198.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$236.72
|
| Rate for Payer: Ohio Health Group HMO |
$201.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$215.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$185.61
|
| Rate for Payer: PHCS Commercial |
$258.24
|
| Rate for Payer: United Healthcare All Payer |
$236.72
|
|
|
INFLUENZA A&B PCR
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
30001372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$95.80 |
| Max. Negotiated Rate |
$258.24 |
| Rate for Payer: Aetna Commercial |
$207.13
|
| Rate for Payer: Anthem Medicaid |
$95.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$134.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.80
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: First Health Commercial |
$255.55
|
| Rate for Payer: Humana Commercial |
$228.65
|
| Rate for Payer: Humana KY Medicaid |
$95.80
|
| Rate for Payer: Humana Medicare Advantage |
$95.80
|
| Rate for Payer: Kentucky WC Medicaid |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$220.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$198.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$236.72
|
| Rate for Payer: Ohio Health Group HMO |
$201.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$215.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$185.61
|
| Rate for Payer: PHCS Commercial |
$258.24
|
| Rate for Payer: United Healthcare All Payer |
$236.72
|
|
|
INFLUENZA A&B PCR
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
30001372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.48 |
| Max. Negotiated Rate |
$191.70 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Ambetter Exchange |
$95.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$95.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$95.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.96
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$84.41
|
| Rate for Payer: Healthspan PPO |
$89.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$95.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$95.80
|
| Rate for Payer: Multiplan PHCS |
$161.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$124.54
|
| Rate for Payer: UHCCP Medicaid |
$94.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$95.80
|
|
|
INFLUENZA A&B RSV PNL
|
Facility
|
OP
|
$469.00
|
|
|
Service Code
|
HCPCS 87631
|
| Hospital Charge Code |
30001387
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$450.24 |
| Rate for Payer: Aetna Commercial |
$361.13
|
| Rate for Payer: Anthem Medicaid |
$142.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$142.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$376.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$199.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$142.63
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: First Health Commercial |
$445.55
|
| Rate for Payer: Humana Commercial |
$398.65
|
| Rate for Payer: Humana KY Medicaid |
$142.63
|
| Rate for Payer: Humana Medicare Advantage |
$142.63
|
| Rate for Payer: Kentucky WC Medicaid |
$144.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$384.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$346.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$412.72
|
| Rate for Payer: Ohio Health Group HMO |
$351.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$408.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.61
|
| Rate for Payer: PHCS Commercial |
$450.24
|
| Rate for Payer: United Healthcare All Payer |
$412.72
|
|
|
INFLUENZA A&B RSV PNL
|
Facility
|
IP
|
$469.00
|
|
|
Service Code
|
HCPCS 87631
|
| Hospital Charge Code |
30001387
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$140.70 |
| Max. Negotiated Rate |
$450.24 |
| Rate for Payer: Aetna Commercial |
$361.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$376.61
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: First Health Commercial |
$445.55
|
| Rate for Payer: Humana Commercial |
$398.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$384.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$346.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$412.72
|
| Rate for Payer: Ohio Health Group HMO |
$351.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$408.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.61
|
| Rate for Payer: PHCS Commercial |
$450.24
|
| Rate for Payer: United Healthcare All Payer |
$412.72
|
|
|
INFLUENZA B AG IF
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 87275
|
| Hospital Charge Code |
30001576
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$43.80 |
| Rate for Payer: Aetna Commercial |
$20.44
|
| Rate for Payer: Ambetter Exchange |
$12.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$12.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$12.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.70
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$10.56
|
| Rate for Payer: Healthspan PPO |
$12.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$12.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.25
|
| Rate for Payer: Multiplan PHCS |
$43.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15.93
|
| Rate for Payer: UHCCP Medicaid |
$25.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$7.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.25
|
|
|
INFLUENZA B AG IF
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 87275
|
| Hospital Charge Code |
30001576
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$70.08 |
| Rate for Payer: Aetna Commercial |
$56.21
|
| Rate for Payer: Anthem Medicaid |
$12.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.25
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$60.59
|
| Rate for Payer: First Health Commercial |
$69.35
|
| Rate for Payer: Humana Commercial |
$62.05
|
| Rate for Payer: Humana KY Medicaid |
$12.25
|
| Rate for Payer: Humana Medicare Advantage |
$12.25
|
| Rate for Payer: Kentucky WC Medicaid |
$12.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.24
|
| Rate for Payer: Ohio Health Group HMO |
$54.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.37
|
| Rate for Payer: PHCS Commercial |
$70.08
|
| Rate for Payer: United Healthcare All Payer |
$64.24
|
|
|
INFLUENZA B AG IF
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 87275
|
| Hospital Charge Code |
30001576
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$70.08 |
| Rate for Payer: Aetna Commercial |
$56.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.62
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$60.59
|
| Rate for Payer: First Health Commercial |
$69.35
|
| Rate for Payer: Humana Commercial |
$62.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.24
|
| Rate for Payer: Ohio Health Group HMO |
$54.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.37
|
| Rate for Payer: PHCS Commercial |
$70.08
|
| Rate for Payer: United Healthcare All Payer |
$64.24
|
|
|
INFLUENZA DNA AMP 1+ POC
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS 87501
|
| Hospital Charge Code |
30002021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.05 |
| Max. Negotiated Rate |
$115.61 |
| Rate for Payer: Aetna Commercial |
$115.61
|
| Rate for Payer: Ambetter Exchange |
$51.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$51.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$51.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$61.57
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$51.08
|
| Rate for Payer: Healthspan PPO |
$54.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$51.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.31
|
| Rate for Payer: Multiplan PHCS |
$73.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.70
|
| Rate for Payer: UHCCP Medicaid |
$43.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$51.31
|
|
|
INFLUENZA DNA AMP 1+ POC
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 87501
|
| Hospital Charge Code |
30002021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
INFLUENZA DNA AMP 1+ POC
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 87501
|
| Hospital Charge Code |
30002021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$51.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$51.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$71.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.31
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$51.31
|
| Rate for Payer: Humana Medicare Advantage |
$51.31
|
| Rate for Payer: Kentucky WC Medicaid |
$51.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
63600247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
77000021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
77000021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
77000021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Ambetter Exchange |
$10.93
|
| Rate for Payer: Anthem Medicaid |
$18.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$10.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$10.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.12
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Humana Medicaid |
$18.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$26.40
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$10.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.77
|
| Rate for Payer: Molina Healthcare Passport |
$18.40
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.21
|
| Rate for Payer: UHCCP Medicaid |
$19.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$10.93
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
636T0247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
636T0247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
63600247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Ambetter Exchange |
$10.93
|
| Rate for Payer: Anthem Medicaid |
$18.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$10.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$10.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.12
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Humana Medicaid |
$18.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$26.40
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$10.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.77
|
| Rate for Payer: Molina Healthcare Passport |
$18.40
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.21
|
| Rate for Payer: UHCCP Medicaid |
$19.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$10.93
|
|
|
INFLUENZA VACCINE 6-35 MONTHS
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
63600247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTH(T
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
770T0021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
INFLUENZA VACCINE 6-35 MONTH(T
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 90657
|
| Hospital Charge Code |
770T0021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
