|
RUBELLA SCREEN
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 86762
|
| Hospital Charge Code |
30001210
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.39
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Humana Medicare Advantage |
$14.39
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RUNTHROUGH .014 GUIDEWIRE 180
|
Facility
|
OP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem Medicaid |
$526.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Humana KY Medicaid |
$526.17
|
| Rate for Payer: Kentucky WC Medicaid |
$531.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$536.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
RUNTHROUGH .014 GUIDEWIRE 180
|
Facility
|
IP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
RUNTHROUGH .014 GUIDEWIRE 300
|
Facility
|
IP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
RUNTHROUGH .014 GUIDEWIRE 300
|
Facility
|
OP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem Medicaid |
$526.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Humana KY Medicaid |
$526.17
|
| Rate for Payer: Kentucky WC Medicaid |
$531.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$536.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
RUPTURE FETAL MEMBRANE
|
Facility
|
IP
|
$496.00
|
|
|
Service Code
|
HCPCS 84112
|
| Hospital Charge Code |
30000478
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.48 |
| Max. Negotiated Rate |
$476.16 |
| Rate for Payer: Aetna Commercial |
$381.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$398.29
|
| Rate for Payer: Cash Price |
$248.00
|
| Rate for Payer: Cigna Commercial |
$411.68
|
| Rate for Payer: First Health Commercial |
$471.20
|
| Rate for Payer: Humana Commercial |
$421.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$406.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$366.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$436.48
|
| Rate for Payer: Ohio Health Group HMO |
$372.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.76
|
| Rate for Payer: PHCS Commercial |
$476.16
|
| Rate for Payer: United Healthcare All Payer |
$436.48
|
|
|
RUPTURE FETAL MEMBRANE
|
Facility
|
OP
|
$496.00
|
|
|
Service Code
|
HCPCS 84112
|
| Hospital Charge Code |
30000478
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.48 |
| Max. Negotiated Rate |
$476.16 |
| Rate for Payer: Aetna Commercial |
$381.92
|
| Rate for Payer: Anthem Medicaid |
$170.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$398.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.11
|
| Rate for Payer: Cash Price |
$248.00
|
| Rate for Payer: Cash Price |
$248.00
|
| Rate for Payer: Cigna Commercial |
$411.68
|
| Rate for Payer: First Health Commercial |
$471.20
|
| Rate for Payer: Humana Commercial |
$421.60
|
| Rate for Payer: Humana KY Medicaid |
$170.57
|
| Rate for Payer: Humana Medicare Advantage |
$98.11
|
| Rate for Payer: Kentucky WC Medicaid |
$172.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$406.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$366.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$174.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$436.48
|
| Rate for Payer: Ohio Health Group HMO |
$372.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.76
|
| Rate for Payer: PHCS Commercial |
$476.16
|
| Rate for Payer: United Healthcare All Payer |
$436.48
|
|
|
RUQ BILTREE GB LIV PANC CBDLTD
|
Facility
|
OP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem Medicaid |
$336.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Humana KY Medicaid |
$336.68
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$340.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
RUQ BILTREE GB LIV PANC CBDLTD
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$127.27 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
RUQ BILTREE GB LIV PANC CBDLTD
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402P0018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$157.49 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
RUQ BILTREE GB LIV PANC CBDLTD
|
Facility
|
IP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$143.52 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
RUQ BILTREE GB LIV PANC CBDLTD
|
Facility
|
OP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem Medicaid |
$379.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Humana KY Medicaid |
$379.67
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$383.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$387.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
RUQ BILTREE GB LIV PANC CBDLTD
|
Professional
|
Both
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,104.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$662.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$772.80
|
| Rate for Payer: UHCCP Medicaid |
$386.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
RUXIENCE 10mg (100mg Vial)
|
Facility
|
OP
|
$3,906.56
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$3,750.30 |
| Rate for Payer: Aetna Commercial |
$3,008.05
|
| Rate for Payer: Anthem Medicaid |
$1,343.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,047.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.60
|
| Rate for Payer: Cash Price |
$1,953.28
|
| Rate for Payer: Cash Price |
$1,953.28
|
| Rate for Payer: Cigna Commercial |
$3,242.44
|
| Rate for Payer: First Health Commercial |
$3,711.23
|
| Rate for Payer: Humana Commercial |
$3,320.58
|
| Rate for Payer: Humana KY Medicaid |
$1,343.47
|
| Rate for Payer: Humana Medicare Advantage |
$20.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,357.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,203.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,883.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,370.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,437.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,929.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$781.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$507.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.03
|
| Rate for Payer: PHCS Commercial |
$3,750.30
|
| Rate for Payer: United Healthcare All Payer |
$3,437.77
|
|
|
RUXIENCE 10mg (100mg Vial)
|
Facility
|
IP
|
$3,906.56
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$507.85 |
| Max. Negotiated Rate |
$3,750.30 |
| Rate for Payer: Aetna Commercial |
$3,008.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,047.12
|
| Rate for Payer: Cash Price |
$1,953.28
|
| Rate for Payer: Cigna Commercial |
$3,242.44
|
| Rate for Payer: First Health Commercial |
$3,711.23
|
| Rate for Payer: Humana Commercial |
$3,320.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,203.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,883.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,171.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,437.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,929.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$781.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$507.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.03
|
| Rate for Payer: PHCS Commercial |
$3,750.30
|
| Rate for Payer: United Healthcare All Payer |
$3,437.77
|
|
|
RUXIENCE 10mg (500mg Vial)
|
Facility
|
IP
|
$19,532.80
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003979
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,539.26 |
| Max. Negotiated Rate |
$18,751.49 |
| Rate for Payer: Aetna Commercial |
$15,040.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,235.58
|
| Rate for Payer: Cash Price |
$9,766.40
|
| Rate for Payer: Cigna Commercial |
$16,212.22
|
| Rate for Payer: First Health Commercial |
$18,556.16
|
| Rate for Payer: Humana Commercial |
$16,602.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,016.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,415.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,859.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,188.86
|
| Rate for Payer: Ohio Health Group HMO |
$14,649.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,906.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,539.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,055.17
|
| Rate for Payer: PHCS Commercial |
$18,751.49
|
| Rate for Payer: United Healthcare All Payer |
$17,188.86
|
|
|
RUXIENCE 10mg (500mg Vial)
|
Facility
|
OP
|
$19,532.80
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003979
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$18,751.49 |
| Rate for Payer: Aetna Commercial |
$15,040.26
|
| Rate for Payer: Anthem Medicaid |
$6,717.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,235.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.60
|
| Rate for Payer: Cash Price |
$9,766.40
|
| Rate for Payer: Cash Price |
$9,766.40
|
| Rate for Payer: Cigna Commercial |
$16,212.22
|
| Rate for Payer: First Health Commercial |
$18,556.16
|
| Rate for Payer: Humana Commercial |
$16,602.88
|
| Rate for Payer: Humana KY Medicaid |
$6,717.33
|
| Rate for Payer: Humana Medicare Advantage |
$20.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,785.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,016.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,415.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,852.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,188.86
|
| Rate for Payer: Ohio Health Group HMO |
$14,649.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,906.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,539.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,055.17
|
| Rate for Payer: PHCS Commercial |
$18,751.49
|
| Rate for Payer: United Healthcare All Payer |
$17,188.86
|
|
|
RV1 VACC 2 DOSE LIVE ORAL
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
77000030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV1 VACC 2 DOSE LIVE ORAL
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
77000030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV1 VACC 2 DOSE LIVE ORAL
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
77000030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$215.96 |
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$215.96
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
RV1 VACC 2 DOSE LIVE ORAL(T
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
770T0030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV1 VACC 2 DOSE LIVE ORAL(T
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
770T0030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV5 VACC 3 DOSE LIVE ORAL
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
77000029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.20
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RV5 VACC 3 DOSE LIVE ORAL
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
77000029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.20
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RV5 VACC 3 DOSE LIVE ORAL
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
77000029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$149.34 |
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Healthspan PPO |
$83.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$149.34
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
|
