|
SARILUMAB 150mg PFP
|
Facility
|
IP
|
$3,921.56
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$509.80 |
| Max. Negotiated Rate |
$3,764.70 |
| Rate for Payer: Aetna Commercial |
$3,019.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,058.82
|
| Rate for Payer: Cash Price |
$1,960.78
|
| Rate for Payer: Cigna Commercial |
$3,254.89
|
| Rate for Payer: First Health Commercial |
$3,725.48
|
| Rate for Payer: Humana Commercial |
$3,333.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,215.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,894.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,176.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,450.97
|
| Rate for Payer: Ohio Health Group HMO |
$2,941.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$784.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,215.68
|
| Rate for Payer: PHCS Commercial |
$3,764.70
|
| Rate for Payer: United Healthcare All Payer |
$3,450.97
|
|
|
SARILUMAB 200mg PFP
|
Facility
|
IP
|
$3,921.56
|
|
|
Service Code
|
NDC 24592201
|
| Hospital Charge Code |
25004142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$509.80 |
| Max. Negotiated Rate |
$3,764.70 |
| Rate for Payer: Aetna Commercial |
$3,019.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,058.82
|
| Rate for Payer: Cash Price |
$1,960.78
|
| Rate for Payer: Cigna Commercial |
$3,254.89
|
| Rate for Payer: First Health Commercial |
$3,725.48
|
| Rate for Payer: Humana Commercial |
$3,333.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,215.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,894.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,176.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,450.97
|
| Rate for Payer: Ohio Health Group HMO |
$2,941.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$784.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,215.68
|
| Rate for Payer: PHCS Commercial |
$3,764.70
|
| Rate for Payer: United Healthcare All Payer |
$3,450.97
|
|
|
SARILUMAB 200mg PFP
|
Facility
|
OP
|
$3,921.56
|
|
|
Service Code
|
NDC 24592201
|
| Hospital Charge Code |
25004142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$509.80 |
| Max. Negotiated Rate |
$3,764.70 |
| Rate for Payer: Aetna Commercial |
$3,019.60
|
| Rate for Payer: Anthem Medicaid |
$1,348.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,058.82
|
| Rate for Payer: Cash Price |
$1,960.78
|
| Rate for Payer: Cigna Commercial |
$3,254.89
|
| Rate for Payer: First Health Commercial |
$3,725.48
|
| Rate for Payer: Humana Commercial |
$3,333.33
|
| Rate for Payer: Humana KY Medicaid |
$1,348.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,362.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,215.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,894.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,176.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,375.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,450.97
|
| Rate for Payer: Ohio Health Group HMO |
$2,941.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$784.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,215.68
|
| Rate for Payer: PHCS Commercial |
$3,764.70
|
| Rate for Payer: United Healthcare All Payer |
$3,450.97
|
|
|
SARNA SENSI 30 APPLIC/222 ML
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 316023075
|
| Hospital Charge Code |
25003972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna Commercial |
$0.21
|
| Rate for Payer: Anthem Medicaid |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.26
|
| Rate for Payer: Humana Commercial |
$0.23
|
| Rate for Payer: Humana KY Medicaid |
$0.09
|
| Rate for Payer: Kentucky WC Medicaid |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.24
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Payer |
$0.24
|
|
|
SARNA SENSI 30 APPLIC/222 ML
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 316023075
|
| Hospital Charge Code |
25003972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna Commercial |
$0.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.26
|
| Rate for Payer: Humana Commercial |
$0.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.24
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Payer |
$0.24
|
|
|
SARS-COV2 ANTIBODIES
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS 86769
|
| Hospital Charge Code |
30001808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: Anthem Medicaid |
$38.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$42.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$58.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.13
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$92.96
|
| Rate for Payer: First Health Commercial |
$106.40
|
| Rate for Payer: Humana Commercial |
$95.20
|
| Rate for Payer: Humana KY Medicaid |
$38.52
|
| Rate for Payer: Humana Medicare Advantage |
$42.13
|
| Rate for Payer: Kentucky WC Medicaid |
$38.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.56
|
| Rate for Payer: Ohio Health Group HMO |
$84.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.72
|
| Rate for Payer: PHCS Commercial |
$107.52
|
| Rate for Payer: United Healthcare All Payer |
$98.56
|
|
|
SARS-COV2 ANTIBODIES
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS 86769
|
| Hospital Charge Code |
30001808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.94
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$92.96
|
| Rate for Payer: First Health Commercial |
$106.40
|
| Rate for Payer: Humana Commercial |
$95.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.56
|
| Rate for Payer: Ohio Health Group HMO |
$84.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.72
|
| Rate for Payer: PHCS Commercial |
$107.52
|
| Rate for Payer: United Healthcare All Payer |
$98.56
|
|
|
SARS-COV2 ANTIBODIES
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
HCPCS 86769
|
| Hospital Charge Code |
30001808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$112.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Multiplan PHCS |
$67.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.40
|
| Rate for Payer: UHCCP Medicaid |
$39.20
|
|
|
SARS-COV-2 COVID19 Ag
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 87811
|
| Hospital Charge Code |
30002047
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$79.68 |
| Rate for Payer: Aetna Commercial |
$63.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.65
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: First Health Commercial |
$78.85
|
| Rate for Payer: Humana Commercial |
$70.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.04
|
| Rate for Payer: Ohio Health Group HMO |
$62.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.73
|
| Rate for Payer: PHCS Commercial |
$79.68
|
| Rate for Payer: United Healthcare All Payer |
$73.04
|
|
|
SARS-COV-2 COVID19 Ag
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 87811
|
| Hospital Charge Code |
30002047
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$79.68 |
| Rate for Payer: Aetna Commercial |
$63.91
|
| Rate for Payer: Anthem Medicaid |
$28.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$57.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.38
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: First Health Commercial |
$78.85
|
| Rate for Payer: Humana Commercial |
$70.55
|
| Rate for Payer: Humana KY Medicaid |
$28.54
|
| Rate for Payer: Humana Medicare Advantage |
$41.38
|
| Rate for Payer: Kentucky WC Medicaid |
$28.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.04
|
| Rate for Payer: Ohio Health Group HMO |
$62.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.73
|
| Rate for Payer: PHCS Commercial |
$79.68
|
| Rate for Payer: United Healthcare All Payer |
$73.04
|
|
|
SARS-COV-2 COVID19 Ag POC
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 87811
|
| Hospital Charge Code |
30002046
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$79.68 |
| Rate for Payer: Aetna Commercial |
$63.91
|
| Rate for Payer: Anthem Medicaid |
$28.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$57.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.38
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: First Health Commercial |
$78.85
|
| Rate for Payer: Humana Commercial |
$70.55
|
| Rate for Payer: Humana KY Medicaid |
$28.54
|
| Rate for Payer: Humana Medicare Advantage |
$41.38
|
| Rate for Payer: Kentucky WC Medicaid |
$28.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.04
|
| Rate for Payer: Ohio Health Group HMO |
$62.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.73
|
| Rate for Payer: PHCS Commercial |
$79.68
|
| Rate for Payer: United Healthcare All Payer |
$73.04
|
|
|
SARS-COV-2 COVID19 Ag POC
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 87811
|
| Hospital Charge Code |
30002046
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$79.68 |
| Rate for Payer: Aetna Commercial |
$63.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.65
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: First Health Commercial |
$78.85
|
| Rate for Payer: Humana Commercial |
$70.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.04
|
| Rate for Payer: Ohio Health Group HMO |
$62.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.73
|
| Rate for Payer: PHCS Commercial |
$79.68
|
| Rate for Payer: United Healthcare All Payer |
$73.04
|
|
|
SARS-COV-2 COVID19 Ag POC
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS 87811
|
| Hospital Charge Code |
30002046
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$29.05 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$83.00
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: Multiplan PHCS |
$49.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$58.10
|
| Rate for Payer: UHCCP Medicaid |
$29.05
|
|
|
SARS-COV-2 COVID-19 AMP PRB
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS U0002
|
| Hospital Charge Code |
30001784
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.68 |
| Max. Negotiated Rate |
$130.56 |
| Rate for Payer: Aetna Commercial |
$104.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.21
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cigna Commercial |
$112.88
|
| Rate for Payer: First Health Commercial |
$129.20
|
| Rate for Payer: Humana Commercial |
$115.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.68
|
| Rate for Payer: Ohio Health Group HMO |
$102.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.16
|
| Rate for Payer: PHCS Commercial |
$130.56
|
| Rate for Payer: United Healthcare All Payer |
$119.68
|
|
|
SARS-COV-2 COVID-19 AMP PRB
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS U0002
|
| Hospital Charge Code |
30001784
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.68 |
| Max. Negotiated Rate |
$130.56 |
| Rate for Payer: Aetna Commercial |
$104.72
|
| Rate for Payer: Anthem Medicaid |
$46.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$51.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$71.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.31
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cigna Commercial |
$112.88
|
| Rate for Payer: First Health Commercial |
$129.20
|
| Rate for Payer: Humana Commercial |
$115.60
|
| Rate for Payer: Humana KY Medicaid |
$46.77
|
| Rate for Payer: Humana Medicare Advantage |
$51.31
|
| Rate for Payer: Kentucky WC Medicaid |
$47.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.68
|
| Rate for Payer: Ohio Health Group HMO |
$102.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.16
|
| Rate for Payer: PHCS Commercial |
$130.56
|
| Rate for Payer: United Healthcare All Payer |
$119.68
|
|
|
SARS-COV-2 COVID-19 AMP PRB
|
Professional
|
Both
|
$136.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
30001784
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$136.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Multiplan PHCS |
$81.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$95.20
|
| Rate for Payer: UHCCP Medicaid |
$47.60
|
|
|
SARS-COV-2 RAPID COVID-19 AMP
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS U0002
|
| Hospital Charge Code |
30001926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
SARS-COV-2 RAPID COVID-19 AMP
|
Professional
|
Both
|
$132.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
30001926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$132.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Multiplan PHCS |
$79.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$92.40
|
| Rate for Payer: UHCCP Medicaid |
$46.20
|
|
|
SARS-COV-2 RAPID COVID-19 AMP
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS U0002
|
| Hospital Charge Code |
30001926
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem Medicaid |
$45.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$51.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$71.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.31
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Humana KY Medicaid |
$45.39
|
| Rate for Payer: Humana Medicare Advantage |
$51.31
|
| Rate for Payer: Kentucky WC Medicaid |
$45.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
S AUREUS GYRB GENE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001286
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$23.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$23.39
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$23.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
S AUREUS GYRB GENE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001286
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
SAVARY-GILLIARD WIRE GUIDE 250
|
Facility
|
OP
|
$1,931.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.03 |
| Max. Negotiated Rate |
$1,853.76 |
| Rate for Payer: Aetna Commercial |
$1,486.87
|
| Rate for Payer: Anthem Medicaid |
$664.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.18
|
| Rate for Payer: Cash Price |
$965.50
|
| Rate for Payer: Cigna Commercial |
$1,602.73
|
| Rate for Payer: First Health Commercial |
$1,834.45
|
| Rate for Payer: Humana Commercial |
$1,641.35
|
| Rate for Payer: Humana KY Medicaid |
$664.07
|
| Rate for Payer: Kentucky WC Medicaid |
$670.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,583.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,425.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$677.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,699.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,448.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$598.61
|
| Rate for Payer: PHCS Commercial |
$1,853.76
|
| Rate for Payer: United Healthcare All Payer |
$1,699.28
|
|
|
SAVARY-GILLIARD WIRE GUIDE 250
|
Facility
|
IP
|
$1,931.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.03 |
| Max. Negotiated Rate |
$1,853.76 |
| Rate for Payer: Aetna Commercial |
$1,486.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.18
|
| Rate for Payer: Cash Price |
$965.50
|
| Rate for Payer: Cigna Commercial |
$1,602.73
|
| Rate for Payer: First Health Commercial |
$1,834.45
|
| Rate for Payer: Humana Commercial |
$1,641.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,583.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,425.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,699.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,448.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$598.61
|
| Rate for Payer: PHCS Commercial |
$1,853.76
|
| Rate for Payer: United Healthcare All Payer |
$1,699.28
|
|
|
SAVI-06 GAMMA KIT
|
Professional
|
Both
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,023.25 |
| Max. Negotiated Rate |
$11,495.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$11,495.00
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Multiplan PHCS |
$6,897.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8,046.50
|
| Rate for Payer: UHCCP Medicaid |
$4,023.25
|
|
|
SAVI-06 GAMMA KIT
|
Facility
|
OP
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.35 |
| Max. Negotiated Rate |
$11,035.20 |
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Aetna Commercial |
$9,660.95
|
| Rate for Payer: Anthem Medicaid |
$3,953.13
|
| Rate for Payer: Anthem Medicaid |
$4,314.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,786.42
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$6,273.35
|
| Rate for Payer: Cigna Commercial |
$10,413.75
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: First Health Commercial |
$11,919.36
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$10,664.69
|
| Rate for Payer: Humana KY Medicaid |
$3,953.13
|
| Rate for Payer: Humana KY Medicaid |
$4,314.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.72
|
| Rate for Payer: Kentucky WC Medicaid |
$3,993.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,288.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,259.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,764.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,032.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,401.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,041.09
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$9,410.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.47
|
| Rate for Payer: PHCS Commercial |
$12,044.82
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: United Healthcare All Payer |
$11,041.09
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
