|
PREVENT VISIT - 5-11 YR
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
51000105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$211.20 |
| Rate for Payer: Aetna Commercial |
$169.40
|
| Rate for Payer: Anthem Medicaid |
$75.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.60
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$182.60
|
| Rate for Payer: First Health Commercial |
$209.00
|
| Rate for Payer: Humana Commercial |
$187.00
|
| Rate for Payer: Humana KY Medicaid |
$75.66
|
| Rate for Payer: Kentucky WC Medicaid |
$76.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$180.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$162.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$77.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$193.60
|
| Rate for Payer: Ohio Health Group HMO |
$165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$191.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.80
|
| Rate for Payer: PHCS Commercial |
$211.20
|
| Rate for Payer: United Healthcare All Payer |
$193.60
|
|
|
PREVENT VISIT - 5-11 YR(P
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
510P0105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.90 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna Commercial |
$94.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.90
|
| Rate for Payer: Anthem Medicaid |
$78.58
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$122.23
|
| Rate for Payer: Healthspan PPO |
$101.56
|
| Rate for Payer: Humana Medicaid |
$78.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$79.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$80.15
|
| Rate for Payer: Molina Healthcare Passport |
$78.58
|
| Rate for Payer: Multiplan PHCS |
$132.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.00
|
| Rate for Payer: UHCCP Medicaid |
$39.80
|
| Rate for Payer: United Healthcare Non-Options |
$64.88
|
| Rate for Payer: United Healthcare Options |
$53.11
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$79.37
|
|
|
PREVENT VISIT - NEW AGE18-39
|
Professional
|
Both
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
51000326
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.97 |
| Max. Negotiated Rate |
$312.90 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.97
|
| Rate for Payer: Anthem Medicaid |
$95.21
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$95.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.11
|
| Rate for Payer: Molina Healthcare Passport |
$95.21
|
| Rate for Payer: Multiplan PHCS |
$268.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.90
|
| Rate for Payer: UHCCP Medicaid |
$51.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.16
|
|
|
PREVENT VISIT - NEW AGE18-39
|
Facility
|
OP
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
51000326
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.10 |
| Max. Negotiated Rate |
$429.12 |
| Rate for Payer: Aetna Commercial |
$344.19
|
| Rate for Payer: Anthem Medicaid |
$153.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$348.66
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$371.01
|
| Rate for Payer: First Health Commercial |
$424.65
|
| Rate for Payer: Humana Commercial |
$379.95
|
| Rate for Payer: Humana KY Medicaid |
$153.72
|
| Rate for Payer: Kentucky WC Medicaid |
$155.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$366.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$329.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$134.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$156.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$393.36
|
| Rate for Payer: Ohio Health Group HMO |
$335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$308.43
|
| Rate for Payer: PHCS Commercial |
$429.12
|
| Rate for Payer: United Healthcare All Payer |
$393.36
|
|
|
PREVENT VISIT - NEW AGE18-39
|
Facility
|
IP
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
51000326
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.10 |
| Max. Negotiated Rate |
$429.12 |
| Rate for Payer: Aetna Commercial |
$344.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$348.66
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$371.01
|
| Rate for Payer: First Health Commercial |
$424.65
|
| Rate for Payer: Humana Commercial |
$379.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$366.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$329.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$134.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$393.36
|
| Rate for Payer: Ohio Health Group HMO |
$335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$308.43
|
| Rate for Payer: PHCS Commercial |
$429.12
|
| Rate for Payer: United Healthcare All Payer |
$393.36
|
|
|
PREVENT VISIT - NEW AGE18-39(P
|
Professional
|
Both
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
510P0326
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.97 |
| Max. Negotiated Rate |
$312.90 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.97
|
| Rate for Payer: Anthem Medicaid |
$95.21
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$95.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.11
|
| Rate for Payer: Molina Healthcare Passport |
$95.21
|
| Rate for Payer: Multiplan PHCS |
$268.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.90
|
| Rate for Payer: UHCCP Medicaid |
$51.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.16
|
|
|
PREVENT VISIT - NEW AGE5-11 (P
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
510P0098
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$171.50 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.31
|
| Rate for Payer: Anthem Medicaid |
$89.90
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$150.41
|
| Rate for Payer: Healthspan PPO |
$115.91
|
| Rate for Payer: Humana Medicaid |
$89.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.70
|
| Rate for Payer: Molina Healthcare Passport |
$89.90
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$44.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.80
|
|
|
PREVENT VISIT - NEW AGE5-11 Y
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
51000098
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem Medicaid |
$84.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Humana KY Medicaid |
$84.26
|
| Rate for Payer: Kentucky WC Medicaid |
$85.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
PREVENT VISIT - NEW AGE5-11 Y
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
51000098
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$171.50 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.31
|
| Rate for Payer: Anthem Medicaid |
$89.90
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$150.41
|
| Rate for Payer: Healthspan PPO |
$115.91
|
| Rate for Payer: Humana Medicaid |
$89.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.70
|
| Rate for Payer: Molina Healthcare Passport |
$89.90
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$44.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.80
|
|
|
PREVENT VISIT - NEW AGE5-11 Y
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
51000098
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
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 |
$164.50 |
| 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 |
$89.90
|
| 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 |
$116.33
|
| Rate for Payer: Humana Medicaid |
$89.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.70
|
| Rate for Payer: Molina Healthcare Passport |
$89.90
|
| 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 |
$90.80
|
|
|
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 |
$70.50 |
| 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 |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
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 |
$70.50 |
| 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 |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
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 |
$164.50 |
| 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 |
$89.90
|
| 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 |
$116.33
|
| Rate for Payer: Humana Medicaid |
$89.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.70
|
| Rate for Payer: Molina Healthcare Passport |
$89.90
|
| 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 |
$90.80
|
|
|
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 |
$143.50 |
| 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 |
$67.57
|
| 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 |
$67.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.92
|
| Rate for Payer: Molina Healthcare Passport |
$67.57
|
| 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 |
$68.25
|
|
|
PREVENT VISIT - UNDER 1
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.50 |
| 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 |
$164.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.45
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
PREVENT VISIT - UNDER 1
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.50 |
| 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 |
$164.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.45
|
| 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 |
$143.50 |
| 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 |
$67.57
|
| 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 |
$67.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.92
|
| Rate for Payer: Molina Healthcare Passport |
$67.57
|
| 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 |
$68.25
|
|
|
PREVENT VIS NEW 65 & OLDER
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
51000102
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$152.70 |
| 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 |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| 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 |
$152.70 |
| 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 |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| 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 |
$356.30 |
| 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 |
$127.74
|
| 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 |
$127.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.29
|
| Rate for Payer: Molina Healthcare Passport |
$127.74
|
| 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 |
$129.02
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
IP
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
25004236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.74 |
| Max. Negotiated Rate |
$827.96 |
| Rate for Payer: Aetna Commercial |
$664.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.72
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cigna Commercial |
$715.84
|
| Rate for Payer: First Health Commercial |
$819.34
|
| Rate for Payer: Humana Commercial |
$733.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.96
|
| Rate for Payer: Ohio Health Group HMO |
$646.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.10
|
| Rate for Payer: PHCS Commercial |
$827.96
|
| Rate for Payer: United Healthcare All Payer |
$758.96
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
OP
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
63600164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.74 |
| Max. Negotiated Rate |
$827.96 |
| Rate for Payer: Aetna Commercial |
$664.09
|
| Rate for Payer: Anthem Medicaid |
$296.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.72
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cigna Commercial |
$715.84
|
| Rate for Payer: First Health Commercial |
$819.34
|
| Rate for Payer: Humana Commercial |
$733.09
|
| Rate for Payer: Humana KY Medicaid |
$296.60
|
| Rate for Payer: Kentucky WC Medicaid |
$299.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.96
|
| Rate for Payer: Ohio Health Group HMO |
$646.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.10
|
| Rate for Payer: PHCS Commercial |
$827.96
|
| Rate for Payer: United Healthcare All Payer |
$758.96
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Professional
|
Both
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
63600164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$283.72 |
| Max. Negotiated Rate |
$517.48 |
| Rate for Payer: Ambetter Exchange |
$312.90
|
| Rate for Payer: Anthem Medicaid |
$283.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$312.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$312.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$375.48
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Humana Medicaid |
$283.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$312.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$289.39
|
| Rate for Payer: Molina Healthcare Passport |
$283.72
|
| Rate for Payer: Multiplan PHCS |
$517.48
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$406.77
|
| Rate for Payer: UHCCP Medicaid |
$301.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$286.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$312.90
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
OP
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
25004236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.74 |
| Max. Negotiated Rate |
$827.96 |
| Rate for Payer: Aetna Commercial |
$664.09
|
| Rate for Payer: Anthem Medicaid |
$296.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.72
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cigna Commercial |
$715.84
|
| Rate for Payer: First Health Commercial |
$819.34
|
| Rate for Payer: Humana Commercial |
$733.09
|
| Rate for Payer: Humana KY Medicaid |
$296.60
|
| Rate for Payer: Kentucky WC Medicaid |
$299.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.96
|
| Rate for Payer: Ohio Health Group HMO |
$646.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.10
|
| Rate for Payer: PHCS Commercial |
$827.96
|
| Rate for Payer: United Healthcare All Payer |
$758.96
|
|
