MITOMYCIN BLADDER 5MG VIAL
|
Facility
|
IP
|
$1,325.82
|
|
Service Code
|
NDC 25021025020
|
Hospital Charge Code |
25003213
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$172.36 |
Max. Negotiated Rate |
$1,272.79 |
Rate for Payer: Aetna Commercial |
$1,020.88
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.14
|
Rate for Payer: Cash Price |
$662.91
|
Rate for Payer: Cigna Commercial |
$1,100.43
|
Rate for Payer: First Health Commercial |
$1,259.53
|
Rate for Payer: Humana Commercial |
$1,126.95
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.17
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.46
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$397.75
|
Rate for Payer: Ohio Health Choice Commercial |
$1,166.72
|
Rate for Payer: Ohio Health Group HMO |
$994.36
|
Rate for Payer: Ohio Health Group PPO Differential |
$265.16
|
Rate for Payer: Ohio Health Group PPO No Differential |
$172.36
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$411.00
|
Rate for Payer: PHCS Commercial |
$1,272.79
|
Rate for Payer: United Healthcare All Payer |
$1,166.72
|
|
mitoMYcin Ophthalmic 0.2mg KIT
|
Facility
|
OP
|
$1,575.05
|
|
Service Code
|
HCPCS J7315
|
Hospital Charge Code |
25004132
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$204.76 |
Max. Negotiated Rate |
$1,512.05 |
Rate for Payer: Aetna Commercial |
$1,212.79
|
Rate for Payer: Anthem Medicaid |
$541.66
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.54
|
Rate for Payer: Cash Price |
$787.52
|
Rate for Payer: Cigna Commercial |
$1,307.29
|
Rate for Payer: First Health Commercial |
$1,496.30
|
Rate for Payer: Humana Commercial |
$1,338.79
|
Rate for Payer: Humana KY Medicaid |
$541.66
|
Rate for Payer: Kentucky WC Medicaid |
$547.17
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.54
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.39
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$472.52
|
Rate for Payer: Molina Healthcare Medicaid |
$552.53
|
Rate for Payer: Ohio Health Choice Commercial |
$1,386.04
|
Rate for Payer: Ohio Health Group HMO |
$1,181.29
|
Rate for Payer: Ohio Health Group PPO Differential |
$315.01
|
Rate for Payer: Ohio Health Group PPO No Differential |
$204.76
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.27
|
Rate for Payer: PHCS Commercial |
$1,512.05
|
Rate for Payer: United Healthcare All Payer |
$1,386.04
|
|
mitoMYcin Ophthalmic 0.2mg KIT
|
Facility
|
IP
|
$1,575.05
|
|
Service Code
|
HCPCS J7315
|
Hospital Charge Code |
25004132
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$204.76 |
Max. Negotiated Rate |
$1,512.05 |
Rate for Payer: Aetna Commercial |
$1,212.79
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.54
|
Rate for Payer: Cash Price |
$787.52
|
Rate for Payer: Cigna Commercial |
$1,307.29
|
Rate for Payer: First Health Commercial |
$1,496.30
|
Rate for Payer: Humana Commercial |
$1,338.79
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.54
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.39
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$472.52
|
Rate for Payer: Ohio Health Choice Commercial |
$1,386.04
|
Rate for Payer: Ohio Health Group HMO |
$1,181.29
|
Rate for Payer: Ohio Health Group PPO Differential |
$315.01
|
Rate for Payer: Ohio Health Group PPO No Differential |
$204.76
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.27
|
Rate for Payer: PHCS Commercial |
$1,512.05
|
Rate for Payer: United Healthcare All Payer |
$1,386.04
|
|
MITOXANTRONE5MG/2.5ML20MG/10ML
|
Facility
|
OP
|
$545.66
|
|
Service Code
|
HCPCS J9293
|
Hospital Charge Code |
25002662
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$43.58 |
Max. Negotiated Rate |
$523.83 |
Rate for Payer: Aetna Commercial |
$420.16
|
Rate for Payer: Anthem Medicaid |
$187.65
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$43.58
|
Rate for Payer: Anthem POS/PPO/Traditional |
$425.61
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.01
|
Rate for Payer: CareSource Just4Me Medicare |
$58.83
|
Rate for Payer: Cash Price |
$272.83
|
Rate for Payer: Cash Price |
$272.83
|
Rate for Payer: Cigna Commercial |
$452.90
|
Rate for Payer: First Health Commercial |
$518.38
|
Rate for Payer: Humana Commercial |
$463.81
|
Rate for Payer: Humana KY Medicaid |
$187.65
|
Rate for Payer: Humana Medicare Advantage |
$43.58
|
Rate for Payer: Kentucky WC Medicaid |
$189.56
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$447.44
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.70
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$52.29
|
Rate for Payer: Molina Healthcare Medicaid |
$191.42
|
Rate for Payer: Ohio Health Choice Commercial |
$480.18
|
Rate for Payer: Ohio Health Group HMO |
$409.24
|
Rate for Payer: Ohio Health Group PPO Differential |
$109.13
|
Rate for Payer: Ohio Health Group PPO No Differential |
$70.94
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.15
|
Rate for Payer: PHCS Commercial |
$523.83
|
Rate for Payer: United Healthcare All Payer |
$480.18
|
|
MITOXANTRONE5MG/2.5ML20MG/10ML
|
Facility
|
IP
|
$545.66
|
|
Service Code
|
HCPCS J9293
|
Hospital Charge Code |
25002662
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$70.94 |
Max. Negotiated Rate |
$523.83 |
Rate for Payer: Aetna Commercial |
$420.16
|
Rate for Payer: Anthem POS/PPO/Traditional |
$425.61
|
Rate for Payer: Cash Price |
$272.83
|
Rate for Payer: Cigna Commercial |
$452.90
|
Rate for Payer: First Health Commercial |
$518.38
|
Rate for Payer: Humana Commercial |
$463.81
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$447.44
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.70
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$163.70
|
Rate for Payer: Ohio Health Choice Commercial |
$480.18
|
Rate for Payer: Ohio Health Group HMO |
$409.24
|
Rate for Payer: Ohio Health Group PPO Differential |
$109.13
|
Rate for Payer: Ohio Health Group PPO No Differential |
$70.94
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.15
|
Rate for Payer: PHCS Commercial |
$523.83
|
Rate for Payer: United Healthcare All Payer |
$480.18
|
|
MIXED VENOUS PH
|
Facility
|
OP
|
$64.00
|
|
Service Code
|
HCPCS 82800
|
Hospital Charge Code |
30000333
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$8.32 |
Max. Negotiated Rate |
$61.44 |
Rate for Payer: Aetna Commercial |
$49.28
|
Rate for Payer: Anthem Medicaid |
$11.00
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$11.00
|
Rate for Payer: Anthem POS/PPO/Traditional |
$51.39
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15.40
|
Rate for Payer: CareSource Just4Me Medicare |
$11.00
|
Rate for Payer: Cash Price |
$32.00
|
Rate for Payer: Cash Price |
$32.00
|
Rate for Payer: Cigna Commercial |
$53.12
|
Rate for Payer: First Health Commercial |
$60.80
|
Rate for Payer: Humana Commercial |
$54.40
|
Rate for Payer: Humana KY Medicaid |
$11.00
|
Rate for Payer: Humana Medicare Advantage |
$11.00
|
Rate for Payer: Kentucky WC Medicaid |
$11.11
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$52.48
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.23
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$13.20
|
Rate for Payer: Molina Healthcare Medicaid |
$11.22
|
Rate for Payer: Ohio Health Choice Commercial |
$56.32
|
Rate for Payer: Ohio Health Group HMO |
$48.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$12.80
|
Rate for Payer: Ohio Health Group PPO No Differential |
$8.32
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
Rate for Payer: PHCS Commercial |
$61.44
|
Rate for Payer: United Healthcare All Payer |
$56.32
|
|
MIXED VENOUS PH
|
Facility
|
IP
|
$64.00
|
|
Service Code
|
HCPCS 82800
|
Hospital Charge Code |
30000333
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$8.32 |
Max. Negotiated Rate |
$61.44 |
Rate for Payer: Aetna Commercial |
$49.28
|
Rate for Payer: Anthem POS/PPO/Traditional |
$51.39
|
Rate for Payer: Cash Price |
$32.00
|
Rate for Payer: Cigna Commercial |
$53.12
|
Rate for Payer: First Health Commercial |
$60.80
|
Rate for Payer: Humana Commercial |
$54.40
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$52.48
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.23
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$19.20
|
Rate for Payer: Ohio Health Choice Commercial |
$56.32
|
Rate for Payer: Ohio Health Group HMO |
$48.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$12.80
|
Rate for Payer: Ohio Health Group PPO No Differential |
$8.32
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
Rate for Payer: PHCS Commercial |
$61.44
|
Rate for Payer: United Healthcare All Payer |
$56.32
|
|
MIXTER ENDO CHOLANG SET 5FR
|
Facility
|
OP
|
$1,082.20
|
|
Service Code
|
HCPCS C1894
|
Hospital Charge Code |
27000113
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$140.69 |
Max. Negotiated Rate |
$1,038.91 |
Rate for Payer: Aetna Commercial |
$833.29
|
Rate for Payer: Anthem Medicaid |
$372.17
|
Rate for Payer: Anthem POS/PPO/Traditional |
$844.12
|
Rate for Payer: Cash Price |
$541.10
|
Rate for Payer: Cigna Commercial |
$898.23
|
Rate for Payer: First Health Commercial |
$1,028.09
|
Rate for Payer: Humana Commercial |
$919.87
|
Rate for Payer: Humana KY Medicaid |
$372.17
|
Rate for Payer: Kentucky WC Medicaid |
$375.96
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$887.40
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$798.66
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$324.66
|
Rate for Payer: Molina Healthcare Medicaid |
$379.64
|
Rate for Payer: Ohio Health Choice Commercial |
$952.34
|
Rate for Payer: Ohio Health Group HMO |
$811.65
|
Rate for Payer: Ohio Health Group PPO Differential |
$216.44
|
Rate for Payer: Ohio Health Group PPO No Differential |
$140.69
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$335.48
|
Rate for Payer: PHCS Commercial |
$1,038.91
|
Rate for Payer: United Healthcare All Payer |
$952.34
|
|
MIXTER ENDO CHOLANG SET 5FR
|
Facility
|
IP
|
$1,082.20
|
|
Service Code
|
HCPCS C1894
|
Hospital Charge Code |
27000113
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$140.69 |
Max. Negotiated Rate |
$1,038.91 |
Rate for Payer: Aetna Commercial |
$833.29
|
Rate for Payer: Anthem POS/PPO/Traditional |
$844.12
|
Rate for Payer: Cash Price |
$541.10
|
Rate for Payer: Cigna Commercial |
$898.23
|
Rate for Payer: First Health Commercial |
$1,028.09
|
Rate for Payer: Humana Commercial |
$919.87
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$887.40
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$798.66
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$324.66
|
Rate for Payer: Ohio Health Choice Commercial |
$952.34
|
Rate for Payer: Ohio Health Group HMO |
$811.65
|
Rate for Payer: Ohio Health Group PPO Differential |
$216.44
|
Rate for Payer: Ohio Health Group PPO No Differential |
$140.69
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$335.48
|
Rate for Payer: PHCS Commercial |
$1,038.91
|
Rate for Payer: United Healthcare All Payer |
$952.34
|
|
MMR VIRUS IMMUNIZATION
|
Facility
|
IP
|
$242.00
|
|
Service Code
|
HCPCS 90707
|
Hospital Charge Code |
77000039
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$31.46 |
Max. Negotiated Rate |
$232.32 |
Rate for Payer: Aetna Commercial |
$186.34
|
Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
Rate for Payer: Cash Price |
$121.00
|
Rate for Payer: Cigna Commercial |
$200.86
|
Rate for Payer: First Health Commercial |
$229.90
|
Rate for Payer: Humana Commercial |
$205.70
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
Rate for Payer: Ohio Health Group HMO |
$181.50
|
Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
Rate for Payer: PHCS Commercial |
$232.32
|
Rate for Payer: United Healthcare All Payer |
$212.96
|
|
MMR VIRUS IMMUNIZATION
|
Professional
|
Both
|
$242.00
|
|
Service Code
|
HCPCS 90707
|
Hospital Charge Code |
77000039
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$84.70 |
Max. Negotiated Rate |
$242.00 |
Rate for Payer: Buckeye Medicare Advantage |
$242.00
|
Rate for Payer: Cash Price |
$121.00
|
Rate for Payer: Cash Price |
$121.00
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$133.19
|
Rate for Payer: Multiplan PHCS |
$145.20
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$169.40
|
Rate for Payer: UHCCP Medicaid |
$84.70
|
|
MMR VIRUS IMMUNIZATION
|
Facility
|
OP
|
$242.00
|
|
Service Code
|
HCPCS 90707
|
Hospital Charge Code |
77000039
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$31.46 |
Max. Negotiated Rate |
$232.32 |
Rate for Payer: Aetna Commercial |
$186.34
|
Rate for Payer: Anthem Medicaid |
$83.22
|
Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
Rate for Payer: Cash Price |
$121.00
|
Rate for Payer: Cigna Commercial |
$200.86
|
Rate for Payer: First Health Commercial |
$229.90
|
Rate for Payer: Humana Commercial |
$205.70
|
Rate for Payer: Humana KY Medicaid |
$83.22
|
Rate for Payer: Kentucky WC Medicaid |
$84.07
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
Rate for Payer: Molina Healthcare Medicaid |
$84.89
|
Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
Rate for Payer: Ohio Health Group HMO |
$181.50
|
Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
Rate for Payer: PHCS Commercial |
$232.32
|
Rate for Payer: United Healthcare All Payer |
$212.96
|
|
MMR VIRUS IMMUNIZATION(T
|
Facility
|
IP
|
$242.00
|
|
Service Code
|
HCPCS 90707
|
Hospital Charge Code |
770T0039
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$31.46 |
Max. Negotiated Rate |
$232.32 |
Rate for Payer: Aetna Commercial |
$186.34
|
Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
Rate for Payer: Cash Price |
$121.00
|
Rate for Payer: Cigna Commercial |
$200.86
|
Rate for Payer: First Health Commercial |
$229.90
|
Rate for Payer: Humana Commercial |
$205.70
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
Rate for Payer: Ohio Health Group HMO |
$181.50
|
Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
Rate for Payer: PHCS Commercial |
$232.32
|
Rate for Payer: United Healthcare All Payer |
$212.96
|
|
MMR VIRUS IMMUNIZATION(T
|
Facility
|
OP
|
$242.00
|
|
Service Code
|
HCPCS 90707
|
Hospital Charge Code |
770T0039
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$31.46 |
Max. Negotiated Rate |
$232.32 |
Rate for Payer: Aetna Commercial |
$186.34
|
Rate for Payer: Anthem Medicaid |
$83.22
|
Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
Rate for Payer: Cash Price |
$121.00
|
Rate for Payer: Cigna Commercial |
$200.86
|
Rate for Payer: First Health Commercial |
$229.90
|
Rate for Payer: Humana Commercial |
$205.70
|
Rate for Payer: Humana KY Medicaid |
$83.22
|
Rate for Payer: Kentucky WC Medicaid |
$84.07
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
Rate for Payer: Molina Healthcare Medicaid |
$84.89
|
Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
Rate for Payer: Ohio Health Group HMO |
$181.50
|
Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
Rate for Payer: PHCS Commercial |
$232.32
|
Rate for Payer: United Healthcare All Payer |
$212.96
|
|
MMRV VACCINE SC
|
Professional
|
Both
|
$528.00
|
|
Service Code
|
HCPCS 90710
|
Hospital Charge Code |
77000040
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$140.00 |
Max. Negotiated Rate |
$528.00 |
Rate for Payer: Buckeye Medicare Advantage |
$528.00
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Healthspan PPO |
$140.00
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$400.81
|
Rate for Payer: Multiplan PHCS |
$316.80
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.60
|
Rate for Payer: UHCCP Medicaid |
$184.80
|
|
MMRV VACCINE SC
|
Facility
|
IP
|
$528.00
|
|
Service Code
|
HCPCS 90710
|
Hospital Charge Code |
77000040
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$68.64 |
Max. Negotiated Rate |
$506.88 |
Rate for Payer: Aetna Commercial |
$406.56
|
Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cigna Commercial |
$438.24
|
Rate for Payer: First Health Commercial |
$501.60
|
Rate for Payer: Humana Commercial |
$448.80
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$158.40
|
Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
Rate for Payer: Ohio Health Group HMO |
$396.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$105.60
|
Rate for Payer: Ohio Health Group PPO No Differential |
$68.64
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.68
|
Rate for Payer: PHCS Commercial |
$506.88
|
Rate for Payer: United Healthcare All Payer |
$464.64
|
|
MMRV VACCINE SC
|
Facility
|
OP
|
$528.00
|
|
Service Code
|
HCPCS 90710
|
Hospital Charge Code |
77000040
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$68.64 |
Max. Negotiated Rate |
$506.88 |
Rate for Payer: Aetna Commercial |
$406.56
|
Rate for Payer: Anthem Medicaid |
$181.58
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$120.43
|
Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$168.60
|
Rate for Payer: CareSource Just4Me Medicare |
$162.58
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cigna Commercial |
$438.24
|
Rate for Payer: First Health Commercial |
$501.60
|
Rate for Payer: Humana Commercial |
$448.80
|
Rate for Payer: Humana KY Medicaid |
$181.58
|
Rate for Payer: Humana Medicare Advantage |
$120.43
|
Rate for Payer: Kentucky WC Medicaid |
$183.43
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$144.52
|
Rate for Payer: Molina Healthcare Medicaid |
$185.22
|
Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
Rate for Payer: Ohio Health Group HMO |
$396.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$105.60
|
Rate for Payer: Ohio Health Group PPO No Differential |
$68.64
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.68
|
Rate for Payer: PHCS Commercial |
$506.88
|
Rate for Payer: United Healthcare All Payer |
$464.64
|
|
MMRV VACCINE SC(T
|
Facility
|
IP
|
$528.00
|
|
Service Code
|
HCPCS 90710
|
Hospital Charge Code |
770T0040
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$68.64 |
Max. Negotiated Rate |
$506.88 |
Rate for Payer: Aetna Commercial |
$406.56
|
Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cigna Commercial |
$438.24
|
Rate for Payer: First Health Commercial |
$501.60
|
Rate for Payer: Humana Commercial |
$448.80
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$158.40
|
Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
Rate for Payer: Ohio Health Group HMO |
$396.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$105.60
|
Rate for Payer: Ohio Health Group PPO No Differential |
$68.64
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.68
|
Rate for Payer: PHCS Commercial |
$506.88
|
Rate for Payer: United Healthcare All Payer |
$464.64
|
|
MMRV VACCINE SC(T
|
Facility
|
OP
|
$528.00
|
|
Service Code
|
HCPCS 90710
|
Hospital Charge Code |
770T0040
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$68.64 |
Max. Negotiated Rate |
$506.88 |
Rate for Payer: Aetna Commercial |
$406.56
|
Rate for Payer: Anthem Medicaid |
$181.58
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$120.43
|
Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$168.60
|
Rate for Payer: CareSource Just4Me Medicare |
$162.58
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cash Price |
$264.00
|
Rate for Payer: Cigna Commercial |
$438.24
|
Rate for Payer: First Health Commercial |
$501.60
|
Rate for Payer: Humana Commercial |
$448.80
|
Rate for Payer: Humana KY Medicaid |
$181.58
|
Rate for Payer: Humana Medicare Advantage |
$120.43
|
Rate for Payer: Kentucky WC Medicaid |
$183.43
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$144.52
|
Rate for Payer: Molina Healthcare Medicaid |
$185.22
|
Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
Rate for Payer: Ohio Health Group HMO |
$396.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$105.60
|
Rate for Payer: Ohio Health Group PPO No Differential |
$68.64
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.68
|
Rate for Payer: PHCS Commercial |
$506.88
|
Rate for Payer: United Healthcare All Payer |
$464.64
|
|
MNL PREP&INSJ DP RX DLVR DEV
|
Facility
|
OP
|
$105.00
|
|
Service Code
|
HCPCS 20700
|
Hospital Charge Code |
76102822
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$13.65 |
Max. Negotiated Rate |
$100.80 |
Rate for Payer: Aetna Commercial |
$80.85
|
Rate for Payer: Anthem Medicaid |
$36.11
|
Rate for Payer: Anthem POS/PPO/Traditional |
$81.90
|
Rate for Payer: Cash Price |
$52.50
|
Rate for Payer: Cigna Commercial |
$87.15
|
Rate for Payer: First Health Commercial |
$99.75
|
Rate for Payer: Humana Commercial |
$89.25
|
Rate for Payer: Humana KY Medicaid |
$36.11
|
Rate for Payer: Kentucky WC Medicaid |
$36.48
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$86.10
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$77.49
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$31.50
|
Rate for Payer: Molina Healthcare Medicaid |
$36.83
|
Rate for Payer: Ohio Health Choice Commercial |
$92.40
|
Rate for Payer: Ohio Health Group HMO |
$78.75
|
Rate for Payer: Ohio Health Group PPO Differential |
$21.00
|
Rate for Payer: Ohio Health Group PPO No Differential |
$13.65
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.55
|
Rate for Payer: PHCS Commercial |
$100.80
|
Rate for Payer: United Healthcare All Payer |
$92.40
|
|
MNL PREP&INSJ DP RX DLVR DEV
|
Facility
|
IP
|
$105.00
|
|
Service Code
|
HCPCS 20700
|
Hospital Charge Code |
76102822
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$13.65 |
Max. Negotiated Rate |
$100.80 |
Rate for Payer: Aetna Commercial |
$80.85
|
Rate for Payer: Anthem POS/PPO/Traditional |
$81.90
|
Rate for Payer: Cash Price |
$52.50
|
Rate for Payer: Cigna Commercial |
$87.15
|
Rate for Payer: First Health Commercial |
$99.75
|
Rate for Payer: Humana Commercial |
$89.25
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$86.10
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$77.49
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$31.50
|
Rate for Payer: Ohio Health Choice Commercial |
$92.40
|
Rate for Payer: Ohio Health Group HMO |
$78.75
|
Rate for Payer: Ohio Health Group PPO Differential |
$21.00
|
Rate for Payer: Ohio Health Group PPO No Differential |
$13.65
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.55
|
Rate for Payer: PHCS Commercial |
$100.80
|
Rate for Payer: United Healthcare All Payer |
$92.40
|
|
MNL PREP&INSJ DP RX DLVR DEV
|
Professional
|
Both
|
$105.00
|
|
Service Code
|
HCPCS 20700
|
Hospital Charge Code |
76102822
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$36.75 |
Max. Negotiated Rate |
$115.28 |
Rate for Payer: Anthem Medicaid |
$67.81
|
Rate for Payer: Buckeye Medicare Advantage |
$105.00
|
Rate for Payer: Cash Price |
$52.50
|
Rate for Payer: Cash Price |
$52.50
|
Rate for Payer: Humana Medicaid |
$67.81
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$115.28
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.17
|
Rate for Payer: Molina Healthcare Passport |
$67.81
|
Rate for Payer: Multiplan PHCS |
$63.00
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.50
|
Rate for Payer: UHCCP Medicaid |
$36.75
|
Rate for Payer: Wellcare CHIP/Medicaid |
$68.49
|
|
MNL PREP&INSJ I-ARTIC RX DEV
|
Facility
|
OP
|
$170.00
|
|
Service Code
|
HCPCS 20704
|
Hospital Charge Code |
76102861
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$22.10 |
Max. Negotiated Rate |
$163.20 |
Rate for Payer: Aetna Commercial |
$130.90
|
Rate for Payer: Anthem Medicaid |
$58.46
|
Rate for Payer: Anthem POS/PPO/Traditional |
$132.60
|
Rate for Payer: Cash Price |
$85.00
|
Rate for Payer: Cigna Commercial |
$141.10
|
Rate for Payer: First Health Commercial |
$161.50
|
Rate for Payer: Humana Commercial |
$144.50
|
Rate for Payer: Humana KY Medicaid |
$58.46
|
Rate for Payer: Kentucky WC Medicaid |
$59.06
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$139.40
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$125.46
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$51.00
|
Rate for Payer: Molina Healthcare Medicaid |
$59.64
|
Rate for Payer: Ohio Health Choice Commercial |
$149.60
|
Rate for Payer: Ohio Health Group HMO |
$127.50
|
Rate for Payer: Ohio Health Group PPO Differential |
$34.00
|
Rate for Payer: Ohio Health Group PPO No Differential |
$22.10
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.70
|
Rate for Payer: PHCS Commercial |
$163.20
|
Rate for Payer: United Healthcare All Payer |
$149.60
|
|
MNL PREP&INSJ I-ARTIC RX DEV
|
Professional
|
Both
|
$170.00
|
|
Service Code
|
HCPCS 20704
|
Hospital Charge Code |
76102861
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$59.50 |
Max. Negotiated Rate |
$199.92 |
Rate for Payer: Anthem Medicaid |
$117.53
|
Rate for Payer: Buckeye Medicare Advantage |
$170.00
|
Rate for Payer: Cash Price |
$85.00
|
Rate for Payer: Cash Price |
$85.00
|
Rate for Payer: Humana Medicaid |
$117.53
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$199.92
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$119.88
|
Rate for Payer: Molina Healthcare Passport |
$117.53
|
Rate for Payer: Multiplan PHCS |
$102.00
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$119.00
|
Rate for Payer: UHCCP Medicaid |
$59.50
|
Rate for Payer: Wellcare CHIP/Medicaid |
$118.71
|
|
MNL PREP&INSJ I-ARTIC RX DEV
|
Facility
|
IP
|
$170.00
|
|
Service Code
|
HCPCS 20704
|
Hospital Charge Code |
76102861
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$22.10 |
Max. Negotiated Rate |
$163.20 |
Rate for Payer: Aetna Commercial |
$130.90
|
Rate for Payer: Anthem POS/PPO/Traditional |
$132.60
|
Rate for Payer: Cash Price |
$85.00
|
Rate for Payer: Cigna Commercial |
$141.10
|
Rate for Payer: First Health Commercial |
$161.50
|
Rate for Payer: Humana Commercial |
$144.50
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$139.40
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$125.46
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$51.00
|
Rate for Payer: Ohio Health Choice Commercial |
$149.60
|
Rate for Payer: Ohio Health Group HMO |
$127.50
|
Rate for Payer: Ohio Health Group PPO Differential |
$34.00
|
Rate for Payer: Ohio Health Group PPO No Differential |
$22.10
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.70
|
Rate for Payer: PHCS Commercial |
$163.20
|
Rate for Payer: United Healthcare All Payer |
$149.60
|
|