|
BASIC METABOLIC PANEL
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
30000005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$8.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.46
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$8.46
|
| Rate for Payer: Humana Medicare Advantage |
$8.46
|
| Rate for Payer: Kentucky WC Medicaid |
$8.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
BASIC METABOLIC PANEL
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
30000005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
BASIC METABOLIC PANEL
|
Professional
|
Both
|
$69.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
30000005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$14.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$69.00
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$7.44
|
| Rate for Payer: Healthspan PPO |
$7.69
|
| Rate for Payer: Multiplan PHCS |
$41.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$48.30
|
| Rate for Payer: UHCCP Medicaid |
$24.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.08
|
|
|
BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)
|
Facility
|
OP
|
$11.84
|
|
|
Service Code
|
CPT 80048
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$11.84 |
| Rate for Payer: Anthem Medicaid |
$8.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.46
|
| Rate for Payer: Humana KY Medicaid |
$8.46
|
| Rate for Payer: Humana Medicare Advantage |
$8.46
|
| Rate for Payer: Kentucky WC Medicaid |
$8.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.63
|
|
|
BASIC VESTIBULAR EVALUATION
|
Professional
|
Both
|
$539.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
47000004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$80.25 |
| Max. Negotiated Rate |
$539.00 |
| Rate for Payer: Aetna Commercial |
$147.26
|
| Rate for Payer: Anthem Medicaid |
$80.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$539.00
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: Cigna Commercial |
$154.86
|
| Rate for Payer: Healthspan PPO |
$94.80
|
| Rate for Payer: Humana Medicaid |
$80.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.86
|
| Rate for Payer: Molina Healthcare Passport |
$80.25
|
| Rate for Payer: Multiplan PHCS |
$323.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$377.30
|
| Rate for Payer: UHCCP Medicaid |
$188.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.05
|
|
|
BASIC VESTIBULAR EVALUATION
|
Facility
|
OP
|
$539.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
47000004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$70.07 |
| Max. Negotiated Rate |
$517.44 |
| Rate for Payer: Aetna Commercial |
$415.03
|
| Rate for Payer: Anthem Medicaid |
$185.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$420.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: Cigna Commercial |
$447.37
|
| Rate for Payer: First Health Commercial |
$512.05
|
| Rate for Payer: Humana Commercial |
$458.15
|
| Rate for Payer: Humana KY Medicaid |
$185.36
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$187.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$441.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$397.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$474.32
|
| Rate for Payer: Ohio Health Group HMO |
$404.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.09
|
| Rate for Payer: PHCS Commercial |
$517.44
|
| Rate for Payer: United Healthcare All Payer |
$474.32
|
|
|
BASIC VESTIBULAR EVALUATION
|
Facility
|
IP
|
$539.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
47000004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$70.07 |
| Max. Negotiated Rate |
$517.44 |
| Rate for Payer: Aetna Commercial |
$415.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$420.42
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: Cigna Commercial |
$447.37
|
| Rate for Payer: First Health Commercial |
$512.05
|
| Rate for Payer: Humana Commercial |
$458.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$441.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$397.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$474.32
|
| Rate for Payer: Ohio Health Group HMO |
$404.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.09
|
| Rate for Payer: PHCS Commercial |
$517.44
|
| Rate for Payer: United Healthcare All Payer |
$474.32
|
|
|
BASIC VESTIBULAR EVALUATION(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
470P0004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$147.26
|
| Rate for Payer: Anthem Medicaid |
$80.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$154.86
|
| Rate for Payer: Healthspan PPO |
$94.80
|
| Rate for Payer: Humana Medicaid |
$80.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.86
|
| Rate for Payer: Molina Healthcare Passport |
$80.25
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.05
|
|
|
BASIC VESTIBULAR EVALUATION(T
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
470T0004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$44.07 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem Medicaid |
$116.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Humana KY Medicaid |
$116.58
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$117.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$118.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.09
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
BASIC VESTIBULAR EVALUATION(T
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
470T0004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$44.07 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.09
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
BASSINET
|
Facility
|
IP
|
$3,294.00
|
|
| Hospital Charge Code |
17000001
|
|
Hospital Revenue Code
|
170
|
| Min. Negotiated Rate |
$428.22 |
| Max. Negotiated Rate |
$3,162.24 |
| Rate for Payer: Aetna Commercial |
$2,536.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,569.32
|
| Rate for Payer: Cash Price |
$1,647.00
|
| Rate for Payer: Cash Price |
$1,647.00
|
| Rate for Payer: Cigna Commercial |
$2,734.02
|
| Rate for Payer: First Health Commercial |
$3,129.30
|
| Rate for Payer: Humana Commercial |
$2,799.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,701.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,430.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,898.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,470.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$658.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,021.14
|
| Rate for Payer: PHCS Commercial |
$3,162.24
|
| Rate for Payer: United Healthcare All Payer |
$2,898.72
|
|
|
BASSINET INT
|
Facility
|
IP
|
$6,588.00
|
|
| Hospital Charge Code |
17000002
|
|
Hospital Revenue Code
|
170
|
| Min. Negotiated Rate |
$856.44 |
| Max. Negotiated Rate |
$6,324.48 |
| Rate for Payer: Aetna Commercial |
$5,072.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,138.64
|
| Rate for Payer: Cash Price |
$3,294.00
|
| Rate for Payer: Cash Price |
$3,294.00
|
| Rate for Payer: Cigna Commercial |
$5,468.04
|
| Rate for Payer: First Health Commercial |
$6,258.60
|
| Rate for Payer: Humana Commercial |
$5,599.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,402.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,861.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,797.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,941.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,317.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$856.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.28
|
| Rate for Payer: PHCS Commercial |
$6,324.48
|
| Rate for Payer: United Healthcare All Payer |
$5,797.44
|
|
|
BATTERY EACH-ZINC AIR
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
47000036
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$1.92
|
| Rate for Payer: Anthem Medicaid |
$0.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.95
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna Commercial |
$2.08
|
| Rate for Payer: First Health Commercial |
$2.38
|
| Rate for Payer: Humana Commercial |
$2.12
|
| Rate for Payer: Humana KY Medicaid |
$0.86
|
| Rate for Payer: Kentucky WC Medicaid |
$0.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.20
|
| Rate for Payer: Ohio Health Group HMO |
$1.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.78
|
| Rate for Payer: PHCS Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Payer |
$2.20
|
|
|
BATTERY EACH-ZINC AIR
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
47000036
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$1.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.95
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna Commercial |
$2.08
|
| Rate for Payer: First Health Commercial |
$2.38
|
| Rate for Payer: Humana Commercial |
$2.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.20
|
| Rate for Payer: Ohio Health Group HMO |
$1.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.78
|
| Rate for Payer: PHCS Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Payer |
$2.20
|
|
|
BATTERY EACH ZINC AIR SP
|
Professional
|
Both
|
$2.50
|
|
| Hospital Charge Code |
47000103
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Buckeye Medicare Advantage |
$2.50
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Multiplan PHCS |
$1.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.75
|
| Rate for Payer: UHCCP Medicaid |
$0.88
|
|
|
BAXDELA 300MG VIAL
|
Facility
|
IP
|
$569.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.09 |
| Max. Negotiated Rate |
$547.10 |
| Rate for Payer: Aetna Commercial |
$438.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.52
|
| Rate for Payer: Cash Price |
$284.95
|
| Rate for Payer: Cigna Commercial |
$473.02
|
| Rate for Payer: First Health Commercial |
$541.40
|
| Rate for Payer: Humana Commercial |
$484.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$467.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$420.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.51
|
| Rate for Payer: Ohio Health Group HMO |
$427.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$176.67
|
| Rate for Payer: PHCS Commercial |
$547.10
|
| Rate for Payer: United Healthcare All Payer |
$501.51
|
|
|
BAXDELA 300MG VIAL
|
Facility
|
OP
|
$569.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.09 |
| Max. Negotiated Rate |
$547.10 |
| Rate for Payer: Aetna Commercial |
$438.82
|
| Rate for Payer: Anthem Medicaid |
$195.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.52
|
| Rate for Payer: Cash Price |
$284.95
|
| Rate for Payer: Cigna Commercial |
$473.02
|
| Rate for Payer: First Health Commercial |
$541.40
|
| Rate for Payer: Humana Commercial |
$484.42
|
| Rate for Payer: Humana KY Medicaid |
$195.99
|
| Rate for Payer: Kentucky WC Medicaid |
$197.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$467.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$420.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.51
|
| Rate for Payer: Ohio Health Group HMO |
$427.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$176.67
|
| Rate for Payer: PHCS Commercial |
$547.10
|
| Rate for Payer: United Healthcare All Payer |
$501.51
|
|
|
BAXDELA 450MG TABLET
|
Facility
|
IP
|
$151.70
|
|
|
Service Code
|
NDC 70842010101
|
| Hospital Charge Code |
25002875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.72 |
| Max. Negotiated Rate |
$145.63 |
| Rate for Payer: Aetna Commercial |
$116.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.33
|
| Rate for Payer: Cash Price |
$75.85
|
| Rate for Payer: Cigna Commercial |
$125.91
|
| Rate for Payer: First Health Commercial |
$144.12
|
| Rate for Payer: Humana Commercial |
$128.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.50
|
| Rate for Payer: Ohio Health Group HMO |
$113.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.03
|
| Rate for Payer: PHCS Commercial |
$145.63
|
| Rate for Payer: United Healthcare All Payer |
$133.50
|
|
|
BAXDELA 450MG TABLET
|
Facility
|
OP
|
$151.70
|
|
|
Service Code
|
NDC 70842010101
|
| Hospital Charge Code |
25002875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.72 |
| Max. Negotiated Rate |
$145.63 |
| Rate for Payer: Aetna Commercial |
$116.81
|
| Rate for Payer: Anthem Medicaid |
$52.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.33
|
| Rate for Payer: Cash Price |
$75.85
|
| Rate for Payer: Cigna Commercial |
$125.91
|
| Rate for Payer: First Health Commercial |
$144.12
|
| Rate for Payer: Humana Commercial |
$128.94
|
| Rate for Payer: Humana KY Medicaid |
$52.17
|
| Rate for Payer: Kentucky WC Medicaid |
$52.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.50
|
| Rate for Payer: Ohio Health Group HMO |
$113.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.03
|
| Rate for Payer: PHCS Commercial |
$145.63
|
| Rate for Payer: United Healthcare All Payer |
$133.50
|
|
|
BAYHEP B (HEP B IMMGLOBU)
|
Facility
|
IP
|
$357.45
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
25000001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.47 |
| Max. Negotiated Rate |
$343.15 |
| Rate for Payer: Aetna Commercial |
$275.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$278.81
|
| Rate for Payer: Cash Price |
$178.72
|
| Rate for Payer: Cigna Commercial |
$296.68
|
| Rate for Payer: First Health Commercial |
$339.58
|
| Rate for Payer: Humana Commercial |
$303.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$293.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$263.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$314.56
|
| Rate for Payer: Ohio Health Group HMO |
$268.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.81
|
| Rate for Payer: PHCS Commercial |
$343.15
|
| Rate for Payer: United Healthcare All Payer |
$314.56
|
|
|
BAYHEP B (HEP B IMMGLOBU)
|
Facility
|
OP
|
$357.45
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
25000001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.47 |
| Max. Negotiated Rate |
$343.15 |
| Rate for Payer: Aetna Commercial |
$275.24
|
| Rate for Payer: Anthem Medicaid |
$122.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$137.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$278.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$193.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.15
|
| Rate for Payer: Cash Price |
$178.72
|
| Rate for Payer: Cash Price |
$178.72
|
| Rate for Payer: Cigna Commercial |
$296.68
|
| Rate for Payer: First Health Commercial |
$339.58
|
| Rate for Payer: Humana Commercial |
$303.83
|
| Rate for Payer: Humana KY Medicaid |
$122.93
|
| Rate for Payer: Humana Medicare Advantage |
$137.89
|
| Rate for Payer: Kentucky WC Medicaid |
$124.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$293.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$263.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$125.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$314.56
|
| Rate for Payer: Ohio Health Group HMO |
$268.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.81
|
| Rate for Payer: PHCS Commercial |
$343.15
|
| Rate for Payer: United Healthcare All Payer |
$314.56
|
|
|
BBL AA Full Face
|
Professional
|
Both
|
$350.00
|
|
| Hospital Charge Code |
22200265
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
|
|
BBL AAFull Face-PP #1 50%
|
Professional
|
Both
|
$446.00
|
|
| Hospital Charge Code |
22200266
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$156.10 |
| Max. Negotiated Rate |
$446.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$446.00
|
| Rate for Payer: Cash Price |
$223.00
|
| Rate for Payer: Multiplan PHCS |
$267.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.20
|
| Rate for Payer: UHCCP Medicaid |
$156.10
|
|
|
BBL AAFull Face-PP#2/3 25%
|
Professional
|
Both
|
$223.00
|
|
| Hospital Charge Code |
22200497
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$223.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$223.00
|
| Rate for Payer: Cash Price |
$111.50
|
| Rate for Payer: Multiplan PHCS |
$133.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$156.10
|
| Rate for Payer: UHCCP Medicaid |
$78.05
|
|
|
BBL AA Partial Face
|
Professional
|
Both
|
$200.00
|
|
| Hospital Charge Code |
22200267
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
