|
PREVENT VISIT NEW PT AGE 1-4
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
51000097
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
PREVENT VISIT NEW PT AGE 1-4
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
51000097
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem Medicaid |
$80.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Humana KY Medicaid |
$80.82
|
| Rate for Payer: Kentucky WC Medicaid |
$81.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
PREVENT VISIT NEW PT AGE 1-4
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
51000097
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.74 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.74
|
| Rate for Payer: Anthem Medicaid |
$64.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$152.62
|
| Rate for Payer: Healthspan PPO |
$116.32
|
| Rate for Payer: Humana Medicaid |
$64.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.67
|
| Rate for Payer: Molina Healthcare Passport |
$64.38
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$44.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.02
|
|
|
PREVENT VISIT NEW PT AGE 1-4(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
510P0097
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.74 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.74
|
| Rate for Payer: Anthem Medicaid |
$64.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$152.62
|
| Rate for Payer: Healthspan PPO |
$116.32
|
| Rate for Payer: Humana Medicaid |
$64.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.67
|
| Rate for Payer: Molina Healthcare Passport |
$64.38
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$44.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.02
|
|
|
PREVENT VISIT - UNDER 1
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.80 |
| Rate for Payer: Aetna Commercial |
$157.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.90
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$170.15
|
| Rate for Payer: First Health Commercial |
$194.75
|
| Rate for Payer: Humana Commercial |
$174.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.40
|
| Rate for Payer: Ohio Health Group HMO |
$153.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.55
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
PREVENT VISIT - UNDER 1
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna Commercial |
$80.47
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.78
|
| Rate for Payer: Anthem Medicaid |
$55.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.00
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$110.62
|
| Rate for Payer: Healthspan PPO |
$91.25
|
| Rate for Payer: Humana Medicaid |
$55.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.27
|
| Rate for Payer: Molina Healthcare Passport |
$55.17
|
| Rate for Payer: Multiplan PHCS |
$123.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.50
|
| Rate for Payer: UHCCP Medicaid |
$36.52
|
| Rate for Payer: United Healthcare Non-Options |
$55.42
|
| Rate for Payer: United Healthcare Options |
$45.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.72
|
|
|
PREVENT VISIT - UNDER 1
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.80 |
| Rate for Payer: Aetna Commercial |
$157.85
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.90
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$170.15
|
| Rate for Payer: First Health Commercial |
$194.75
|
| Rate for Payer: Humana Commercial |
$174.25
|
| Rate for Payer: Humana KY Medicaid |
$70.50
|
| Rate for Payer: Kentucky WC Medicaid |
$71.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.40
|
| Rate for Payer: Ohio Health Group HMO |
$153.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.55
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
PREVENT VISIT - UNDER 1(P
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
510P0103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna Commercial |
$80.47
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.78
|
| Rate for Payer: Anthem Medicaid |
$55.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.00
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$110.62
|
| Rate for Payer: Healthspan PPO |
$91.25
|
| Rate for Payer: Humana Medicaid |
$55.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.27
|
| Rate for Payer: Molina Healthcare Passport |
$55.17
|
| Rate for Payer: Multiplan PHCS |
$123.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.50
|
| Rate for Payer: UHCCP Medicaid |
$36.52
|
| Rate for Payer: United Healthcare Non-Options |
$55.42
|
| Rate for Payer: United Healthcare Options |
$45.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.72
|
|
|
PREVENT VIS NEW 65 & OLDER
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
51000102
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.17 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$157.79
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
PREVENT VIS NEW 65 & OLDER
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
51000102
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.17 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem Medicaid |
$175.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Humana KY Medicaid |
$175.05
|
| Rate for Payer: Kentucky WC Medicaid |
$176.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$157.79
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
PREVENT VIS NEW 65 & OLDER
|
Professional
|
Both
|
$509.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
51000102
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.93 |
| Max. Negotiated Rate |
$509.00 |
| Rate for Payer: Aetna Commercial |
$162.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.93
|
| Rate for Payer: Anthem Medicaid |
$101.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$509.00
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$208.03
|
| Rate for Payer: Healthspan PPO |
$162.38
|
| Rate for Payer: Humana Medicaid |
$101.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.43
|
| Rate for Payer: Molina Healthcare Passport |
$101.40
|
| Rate for Payer: Multiplan PHCS |
$305.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$356.30
|
| Rate for Payer: UHCCP Medicaid |
$70.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.41
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
IP
|
$795.05
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
63600164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.36 |
| Max. Negotiated Rate |
$763.25 |
| Rate for Payer: Aetna Commercial |
$612.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.14
|
| Rate for Payer: Cash Price |
$397.52
|
| Rate for Payer: Cigna Commercial |
$659.89
|
| Rate for Payer: First Health Commercial |
$755.30
|
| Rate for Payer: Humana Commercial |
$675.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.64
|
| Rate for Payer: Ohio Health Group HMO |
$596.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.47
|
| Rate for Payer: PHCS Commercial |
$763.25
|
| Rate for Payer: United Healthcare All Payer |
$699.64
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
OP
|
$795.05
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
63600164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.36 |
| Max. Negotiated Rate |
$763.25 |
| Rate for Payer: Aetna Commercial |
$612.19
|
| Rate for Payer: Anthem Medicaid |
$273.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.14
|
| Rate for Payer: Cash Price |
$397.52
|
| Rate for Payer: Cigna Commercial |
$659.89
|
| Rate for Payer: First Health Commercial |
$755.30
|
| Rate for Payer: Humana Commercial |
$675.79
|
| Rate for Payer: Humana KY Medicaid |
$273.42
|
| Rate for Payer: Kentucky WC Medicaid |
$276.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.64
|
| Rate for Payer: Ohio Health Group HMO |
$596.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.47
|
| Rate for Payer: PHCS Commercial |
$763.25
|
| Rate for Payer: United Healthcare All Payer |
$699.64
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Professional
|
Both
|
$795.05
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
63600164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$278.27 |
| Max. Negotiated Rate |
$795.05 |
| Rate for Payer: Buckeye Medicare Advantage |
$795.05
|
| Rate for Payer: Cash Price |
$397.52
|
| Rate for Payer: Multiplan PHCS |
$477.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$556.54
|
| Rate for Payer: UHCCP Medicaid |
$278.27
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
OP
|
$795.05
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
636T0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.36 |
| Max. Negotiated Rate |
$763.25 |
| Rate for Payer: Aetna Commercial |
$612.19
|
| Rate for Payer: Anthem Medicaid |
$273.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.14
|
| Rate for Payer: Cash Price |
$397.52
|
| Rate for Payer: Cigna Commercial |
$659.89
|
| Rate for Payer: First Health Commercial |
$755.30
|
| Rate for Payer: Humana Commercial |
$675.79
|
| Rate for Payer: Humana KY Medicaid |
$273.42
|
| Rate for Payer: Kentucky WC Medicaid |
$276.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.64
|
| Rate for Payer: Ohio Health Group HMO |
$596.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.47
|
| Rate for Payer: PHCS Commercial |
$763.25
|
| Rate for Payer: United Healthcare All Payer |
$699.64
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
IP
|
$795.05
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
636T0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.36 |
| Max. Negotiated Rate |
$763.25 |
| Rate for Payer: Aetna Commercial |
$612.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.14
|
| Rate for Payer: Cash Price |
$397.52
|
| Rate for Payer: Cigna Commercial |
$659.89
|
| Rate for Payer: First Health Commercial |
$755.30
|
| Rate for Payer: Humana Commercial |
$675.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.64
|
| Rate for Payer: Ohio Health Group HMO |
$596.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.47
|
| Rate for Payer: PHCS Commercial |
$763.25
|
| Rate for Payer: United Healthcare All Payer |
$699.64
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
IP
|
$849.01
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
25004236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.37 |
| Max. Negotiated Rate |
$815.05 |
| Rate for Payer: Aetna Commercial |
$653.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$662.23
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$704.68
|
| Rate for Payer: First Health Commercial |
$806.56
|
| Rate for Payer: Humana Commercial |
$721.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$696.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$626.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$747.13
|
| Rate for Payer: Ohio Health Group HMO |
$636.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$169.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.19
|
| Rate for Payer: PHCS Commercial |
$815.05
|
| Rate for Payer: United Healthcare All Payer |
$747.13
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
OP
|
$849.01
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
25004236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.37 |
| Max. Negotiated Rate |
$815.05 |
| Rate for Payer: Aetna Commercial |
$653.74
|
| Rate for Payer: Anthem Medicaid |
$291.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$662.23
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$704.68
|
| Rate for Payer: First Health Commercial |
$806.56
|
| Rate for Payer: Humana Commercial |
$721.66
|
| Rate for Payer: Humana KY Medicaid |
$291.97
|
| Rate for Payer: Kentucky WC Medicaid |
$294.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$696.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$626.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$297.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$747.13
|
| Rate for Payer: Ohio Health Group HMO |
$636.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$169.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.19
|
| Rate for Payer: PHCS Commercial |
$815.05
|
| Rate for Payer: United Healthcare All Payer |
$747.13
|
|
|
PREV VISIT NEW AGE 12-17
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.25
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
PREV VISIT NEW AGE 12-17
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$94.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$94.57
|
| Rate for Payer: Kentucky WC Medicaid |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$96.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.25
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
PREV VISIT NEW AGE 12-17
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$80.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$80.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.03
|
| Rate for Payer: Molina Healthcare Passport |
$80.42
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.22
|
|
|
PREV VISIT NEW AGE 12-17(P
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
510P0099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$80.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$80.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.03
|
| Rate for Payer: Molina Healthcare Passport |
$80.42
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.22
|
|
|
PREZISTA (DARUNAVIR) 800MG
|
Facility
|
IP
|
$143.94
|
|
|
Service Code
|
NDC 59676056630
|
| Hospital Charge Code |
25003813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.71 |
| Max. Negotiated Rate |
$138.18 |
| Rate for Payer: Aetna Commercial |
$110.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.27
|
| Rate for Payer: Cash Price |
$71.97
|
| Rate for Payer: Cigna Commercial |
$119.47
|
| Rate for Payer: First Health Commercial |
$136.74
|
| Rate for Payer: Humana Commercial |
$122.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.67
|
| Rate for Payer: Ohio Health Group HMO |
$107.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.62
|
| Rate for Payer: PHCS Commercial |
$138.18
|
| Rate for Payer: United Healthcare All Payer |
$126.67
|
|
|
PREZISTA (DARUNAVIR) 800MG
|
Facility
|
OP
|
$143.94
|
|
|
Service Code
|
NDC 59676056630
|
| Hospital Charge Code |
25003813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.71 |
| Max. Negotiated Rate |
$138.18 |
| Rate for Payer: Aetna Commercial |
$110.83
|
| Rate for Payer: Anthem Medicaid |
$49.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.27
|
| Rate for Payer: Cash Price |
$71.97
|
| Rate for Payer: Cigna Commercial |
$119.47
|
| Rate for Payer: First Health Commercial |
$136.74
|
| Rate for Payer: Humana Commercial |
$122.35
|
| Rate for Payer: Humana KY Medicaid |
$49.50
|
| Rate for Payer: Kentucky WC Medicaid |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.67
|
| Rate for Payer: Ohio Health Group HMO |
$107.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.62
|
| Rate for Payer: PHCS Commercial |
$138.18
|
| Rate for Payer: United Healthcare All Payer |
$126.67
|
|
|
PRGRMG DEV EVAL SCRMS IP
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS 93285
|
| Hospital Charge Code |
48000082
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem Medicaid |
$67.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.02
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Humana KY Medicaid |
$67.40
|
| Rate for Payer: Humana Medicare Advantage |
$32.61
|
| Rate for Payer: Kentucky WC Medicaid |
$68.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.76
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
