|
MITOMYCIN 5MG(40MG SDV)BLADDER
|
Facility
|
OP
|
$6,888.58
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$6,613.04 |
| Rate for Payer: Aetna Commercial |
$5,304.21
|
| Rate for Payer: Anthem Medicaid |
$2,368.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,373.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.16
|
| Rate for Payer: Cash Price |
$3,444.29
|
| Rate for Payer: Cash Price |
$3,444.29
|
| Rate for Payer: Cigna Commercial |
$5,717.52
|
| Rate for Payer: First Health Commercial |
$6,544.15
|
| Rate for Payer: Humana Commercial |
$5,855.29
|
| Rate for Payer: Humana KY Medicaid |
$2,368.98
|
| Rate for Payer: Humana Medicare Advantage |
$28.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,393.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,510.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,993.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,753.12
|
| Rate for Payer: PHCS Commercial |
$6,613.04
|
| Rate for Payer: United Healthcare All Payer |
$6,061.95
|
|
|
MITOMYCIN BLADDER 20MG VIAL
|
Facility
|
IP
|
$3,444.40
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002660
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,033.32 |
| Max. Negotiated Rate |
$3,306.62 |
| Rate for Payer: Aetna Commercial |
$2,652.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.63
|
| Rate for Payer: Cash Price |
$1,722.20
|
| Rate for Payer: Cigna Commercial |
$2,858.85
|
| Rate for Payer: First Health Commercial |
$3,272.18
|
| Rate for Payer: Humana Commercial |
$2,927.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,031.07
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,755.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.64
|
| Rate for Payer: PHCS Commercial |
$3,306.62
|
| Rate for Payer: United Healthcare All Payer |
$3,031.07
|
|
|
MITOMYCIN BLADDER 20MG VIAL
|
Facility
|
OP
|
$3,444.40
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002660
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$3,306.62 |
| Rate for Payer: Aetna Commercial |
$2,652.19
|
| Rate for Payer: Anthem Medicaid |
$1,184.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.16
|
| Rate for Payer: Cash Price |
$1,722.20
|
| Rate for Payer: Cash Price |
$1,722.20
|
| Rate for Payer: Cigna Commercial |
$2,858.85
|
| Rate for Payer: First Health Commercial |
$3,272.18
|
| Rate for Payer: Humana Commercial |
$2,927.74
|
| Rate for Payer: Humana KY Medicaid |
$1,184.53
|
| Rate for Payer: Humana Medicare Advantage |
$28.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,196.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,208.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,031.07
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,755.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.64
|
| Rate for Payer: PHCS Commercial |
$3,306.62
|
| Rate for Payer: United Healthcare All Payer |
$3,031.07
|
|
|
MITOMYCIN BLADDER 5MG VIAL
|
Facility
|
OP
|
$1,325.82
|
|
|
Service Code
|
NDC 25021025020
|
| Hospital Charge Code |
25003213
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.75 |
| Max. Negotiated Rate |
$1,272.79 |
| Rate for Payer: Aetna Commercial |
$1,020.88
|
| Rate for Payer: Anthem Medicaid |
$455.95
|
| 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: Humana KY Medicaid |
$455.95
|
| Rate for Payer: Kentucky WC Medicaid |
$460.59
|
| 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: Molina Healthcare Medicaid |
$465.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.72
|
| Rate for Payer: Ohio Health Group HMO |
$994.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,153.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.82
|
| Rate for Payer: PHCS Commercial |
$1,272.79
|
| Rate for Payer: United Healthcare All Payer |
$1,166.72
|
|
|
MITOMYCIN BLADDER 5MG VIAL
|
Facility
|
IP
|
$1,325.82
|
|
|
Service Code
|
NDC 25021025020
|
| Hospital Charge Code |
25003213
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.75 |
| 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 |
$994.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,153.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.82
|
| Rate for Payer: PHCS Commercial |
$1,272.79
|
| Rate for Payer: United Healthcare All Payer |
$1,166.72
|
|
|
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 |
$472.51 |
| 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 |
$472.51
|
| 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 |
$1,260.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,370.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,086.78
|
| Rate for Payer: PHCS Commercial |
$1,512.05
|
| Rate for Payer: United Healthcare All Payer |
$1,386.04
|
|
|
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 |
$472.51 |
| 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 |
$472.51
|
| 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 |
$1,260.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,370.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,086.78
|
| 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 |
$29.60 |
| 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 |
$29.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$41.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$39.96
|
| 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 |
$29.60
|
| 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 |
$35.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$480.18
|
| Rate for Payer: Ohio Health Group HMO |
$409.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$436.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$474.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.51
|
| 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 |
$163.70 |
| 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 |
$409.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$436.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$474.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.51
|
| Rate for Payer: PHCS Commercial |
$523.83
|
| Rate for Payer: United Healthcare All Payer |
$480.18
|
|
|
MIXED VENOUS PH
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 82800
|
| Hospital Charge Code |
30000333
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$11.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.00
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$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 |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
MIXED VENOUS PH
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 82800
|
| Hospital Charge Code |
30000333
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.80
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
MIXTER ENDO CHOLANG SET 5FR
|
Facility
|
IP
|
$1,120.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$862.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$873.60
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$929.60
|
| Rate for Payer: First Health Commercial |
$1,064.00
|
| Rate for Payer: Humana Commercial |
$952.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$918.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$826.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$985.60
|
| Rate for Payer: Ohio Health Group HMO |
$840.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$896.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$974.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.80
|
| Rate for Payer: PHCS Commercial |
$1,075.20
|
| Rate for Payer: United Healthcare All Payer |
$985.60
|
|
|
MIXTER ENDO CHOLANG SET 5FR
|
Facility
|
OP
|
$1,120.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$862.40
|
| Rate for Payer: Anthem Medicaid |
$385.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$873.60
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$929.60
|
| Rate for Payer: First Health Commercial |
$1,064.00
|
| Rate for Payer: Humana Commercial |
$952.00
|
| Rate for Payer: Humana KY Medicaid |
$385.17
|
| Rate for Payer: Kentucky WC Medicaid |
$389.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$918.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$826.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$392.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$985.60
|
| Rate for Payer: Ohio Health Group HMO |
$840.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$896.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$974.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.80
|
| Rate for Payer: PHCS Commercial |
$1,075.20
|
| Rate for Payer: United Healthcare All Payer |
$985.60
|
|
|
MMR VIRUS IMMUNIZATION
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
77000039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| 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 |
$169.40 |
| Rate for Payer: Anthem Medicaid |
$87.31
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Humana Medicaid |
$87.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$133.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$89.06
|
| Rate for Payer: Molina Healthcare Passport |
$87.31
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$88.18
|
|
|
MMR VIRUS IMMUNIZATION
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
77000039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| 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 |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| 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 |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
MMRV VACCINE SC
|
Facility
|
IP
|
$528.00
|
|
|
Service Code
|
HCPCS 90710
|
| Hospital Charge Code |
77000040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.40 |
| 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 |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| Rate for Payer: PHCS Commercial |
$506.88
|
| Rate for Payer: United Healthcare All Payer |
$464.64
|
|
|
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 |
$400.81 |
| Rate for Payer: Anthem Medicaid |
$157.64
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Healthspan PPO |
$140.00
|
| Rate for Payer: Humana Medicaid |
$157.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$400.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$160.79
|
| Rate for Payer: Molina Healthcare Passport |
$157.64
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$159.22
|
|
|
MMRV VACCINE SC
|
Facility
|
OP
|
$528.00
|
|
|
Service Code
|
HCPCS 90710
|
| Hospital Charge Code |
77000040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$506.88 |
| Rate for Payer: Aetna Commercial |
$406.56
|
| Rate for Payer: Anthem Medicaid |
$181.58
|
| 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: Humana KY Medicaid |
$181.58
|
| 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 |
$158.40
|
| 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 |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| 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 |
$158.40 |
| Max. Negotiated Rate |
$506.88 |
| Rate for Payer: Aetna Commercial |
$406.56
|
| Rate for Payer: Anthem Medicaid |
$181.58
|
| 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: Humana KY Medicaid |
$181.58
|
| 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 |
$158.40
|
| 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 |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| 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 |
$158.40 |
| 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 |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| 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 |
$31.50 |
| 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 |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.45
|
| 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 |
$31.50 |
| 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 |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.45
|
| Rate for Payer: PHCS Commercial |
$100.80
|
| Rate for Payer: United Healthcare All Payer |
$92.40
|
|
