|
SUBLOCADE 100mg SYRINGE
|
Facility
|
IP
|
$10,990.03
|
|
|
Service Code
|
HCPCS Q9991
|
| Hospital Charge Code |
25004127
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,428.70 |
| Max. Negotiated Rate |
$10,550.43 |
| Rate for Payer: Aetna Commercial |
$8,462.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,572.22
|
| Rate for Payer: Cash Price |
$5,495.02
|
| Rate for Payer: Cigna Commercial |
$9,121.72
|
| Rate for Payer: First Health Commercial |
$10,440.53
|
| Rate for Payer: Humana Commercial |
$9,341.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,011.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,110.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,297.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,671.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,242.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,198.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,428.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,406.91
|
| Rate for Payer: PHCS Commercial |
$10,550.43
|
| Rate for Payer: United Healthcare All Payer |
$9,671.23
|
|
|
SUBLOCADE 100mg SYRINGE
|
Facility
|
OP
|
$10,990.03
|
|
|
Service Code
|
HCPCS Q9991
|
| Hospital Charge Code |
25004127
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,428.70 |
| Max. Negotiated Rate |
$10,550.43 |
| Rate for Payer: Aetna Commercial |
$8,462.32
|
| Rate for Payer: Anthem Medicaid |
$3,779.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,887.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,572.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,641.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,547.60
|
| Rate for Payer: Cash Price |
$5,495.02
|
| Rate for Payer: Cash Price |
$5,495.02
|
| Rate for Payer: Cigna Commercial |
$9,121.72
|
| Rate for Payer: First Health Commercial |
$10,440.53
|
| Rate for Payer: Humana Commercial |
$9,341.53
|
| Rate for Payer: Humana KY Medicaid |
$3,779.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,887.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,817.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,011.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,110.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,264.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,855.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,671.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,242.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,198.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,428.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,406.91
|
| Rate for Payer: PHCS Commercial |
$10,550.43
|
| Rate for Payer: United Healthcare All Payer |
$9,671.23
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
OP
|
$10,082.63
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
63600156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,310.74 |
| Max. Negotiated Rate |
$9,679.32 |
| Rate for Payer: Aetna Commercial |
$7,763.63
|
| Rate for Payer: Anthem Medicaid |
$3,467.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,887.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,864.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,641.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,547.60
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cigna Commercial |
$8,368.58
|
| Rate for Payer: First Health Commercial |
$9,578.50
|
| Rate for Payer: Humana Commercial |
$8,570.24
|
| Rate for Payer: Humana KY Medicaid |
$3,467.42
|
| Rate for Payer: Humana Medicare Advantage |
$1,887.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,264.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,872.71
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.62
|
| Rate for Payer: PHCS Commercial |
$9,679.32
|
| Rate for Payer: United Healthcare All Payer |
$8,872.71
|
|
|
SUBLOCADE 300mg SYRINGE
|
Professional
|
Both
|
$10,082.63
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
63600156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,462.57 |
| Max. Negotiated Rate |
$10,082.63 |
| Rate for Payer: Buckeye Medicare Advantage |
$10,082.63
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,462.57
|
| Rate for Payer: Multiplan PHCS |
$6,049.58
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7,057.84
|
| Rate for Payer: UHCCP Medicaid |
$3,528.92
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
IP
|
$10,990.03
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
25004128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,428.70 |
| Max. Negotiated Rate |
$10,550.43 |
| Rate for Payer: Aetna Commercial |
$8,462.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,572.22
|
| Rate for Payer: Cash Price |
$5,495.02
|
| Rate for Payer: Cigna Commercial |
$9,121.72
|
| Rate for Payer: First Health Commercial |
$10,440.53
|
| Rate for Payer: Humana Commercial |
$9,341.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,011.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,110.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,297.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,671.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,242.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,198.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,428.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,406.91
|
| Rate for Payer: PHCS Commercial |
$10,550.43
|
| Rate for Payer: United Healthcare All Payer |
$9,671.23
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
OP
|
$10,990.03
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
25004128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,428.70 |
| Max. Negotiated Rate |
$10,550.43 |
| Rate for Payer: Aetna Commercial |
$8,462.32
|
| Rate for Payer: Anthem Medicaid |
$3,779.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,887.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,572.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,641.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,547.60
|
| Rate for Payer: Cash Price |
$5,495.02
|
| Rate for Payer: Cash Price |
$5,495.02
|
| Rate for Payer: Cigna Commercial |
$9,121.72
|
| Rate for Payer: First Health Commercial |
$10,440.53
|
| Rate for Payer: Humana Commercial |
$9,341.53
|
| Rate for Payer: Humana KY Medicaid |
$3,779.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,887.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,817.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,011.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,110.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,264.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,855.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,671.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,242.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,198.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,428.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,406.91
|
| Rate for Payer: PHCS Commercial |
$10,550.43
|
| Rate for Payer: United Healthcare All Payer |
$9,671.23
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
OP
|
$10,082.63
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
636T0156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,310.74 |
| Max. Negotiated Rate |
$9,679.32 |
| Rate for Payer: Aetna Commercial |
$7,763.63
|
| Rate for Payer: Anthem Medicaid |
$3,467.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,887.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,864.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,641.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,547.60
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cigna Commercial |
$8,368.58
|
| Rate for Payer: First Health Commercial |
$9,578.50
|
| Rate for Payer: Humana Commercial |
$8,570.24
|
| Rate for Payer: Humana KY Medicaid |
$3,467.42
|
| Rate for Payer: Humana Medicare Advantage |
$1,887.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,264.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,872.71
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.62
|
| Rate for Payer: PHCS Commercial |
$9,679.32
|
| Rate for Payer: United Healthcare All Payer |
$8,872.71
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
IP
|
$10,082.63
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
63600156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,310.74 |
| Max. Negotiated Rate |
$9,679.32 |
| Rate for Payer: Aetna Commercial |
$7,763.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,864.45
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cigna Commercial |
$8,368.58
|
| Rate for Payer: First Health Commercial |
$9,578.50
|
| Rate for Payer: Humana Commercial |
$8,570.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,872.71
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.62
|
| Rate for Payer: PHCS Commercial |
$9,679.32
|
| Rate for Payer: United Healthcare All Payer |
$8,872.71
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
IP
|
$10,082.63
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
636T0156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,310.74 |
| Max. Negotiated Rate |
$9,679.32 |
| Rate for Payer: Aetna Commercial |
$7,763.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,864.45
|
| Rate for Payer: Cash Price |
$5,041.31
|
| Rate for Payer: Cigna Commercial |
$8,368.58
|
| Rate for Payer: First Health Commercial |
$9,578.50
|
| Rate for Payer: Humana Commercial |
$8,570.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,872.71
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.62
|
| Rate for Payer: PHCS Commercial |
$9,679.32
|
| Rate for Payer: United Healthcare All Payer |
$8,872.71
|
|
|
SUBLTVE LMTD FACLSR-PP#2/3 25%
|
Professional
|
Both
|
$159.00
|
|
| Hospital Charge Code |
22200451
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$159.00
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Multiplan PHCS |
$95.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$111.30
|
| Rate for Payer: UHCCP Medicaid |
$55.65
|
|
|
SUBLTVE LOWREYELIDS-PP#2/3 25%
|
Professional
|
Both
|
$159.00
|
|
| Hospital Charge Code |
22200402
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$159.00
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Multiplan PHCS |
$95.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$111.30
|
| Rate for Payer: UHCCP Medicaid |
$55.65
|
|
|
SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD
|
Facility
|
OP
|
$3,897.84
|
|
|
Service Code
|
CPT 30140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,784.17 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
|
|
SUBOXONE 2MG/ 0.5MG COMB
|
Facility
|
IP
|
$60.93
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
25001896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$58.49 |
| Rate for Payer: Aetna Commercial |
$46.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.53
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Cigna Commercial |
$50.57
|
| Rate for Payer: First Health Commercial |
$57.88
|
| Rate for Payer: Humana Commercial |
$51.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.62
|
| Rate for Payer: Ohio Health Group HMO |
$45.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.89
|
| Rate for Payer: PHCS Commercial |
$58.49
|
| Rate for Payer: United Healthcare All Payer |
$53.62
|
|
|
SUBOXONE 2MG/ 0.5MG COMB
|
Facility
|
OP
|
$60.93
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
25001896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$58.49 |
| Rate for Payer: Aetna Commercial |
$46.92
|
| Rate for Payer: Anthem Medicaid |
$20.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.53
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Cigna Commercial |
$50.57
|
| Rate for Payer: First Health Commercial |
$57.88
|
| Rate for Payer: Humana Commercial |
$51.79
|
| Rate for Payer: Humana KY Medicaid |
$20.95
|
| Rate for Payer: Kentucky WC Medicaid |
$21.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.62
|
| Rate for Payer: Ohio Health Group HMO |
$45.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.89
|
| Rate for Payer: PHCS Commercial |
$58.49
|
| Rate for Payer: United Healthcare All Payer |
$53.62
|
|
|
SUBOXONE 8MG/2MG TABLET COMB
|
Facility
|
OP
|
$60.93
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
25001897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$58.49 |
| Rate for Payer: Aetna Commercial |
$46.92
|
| Rate for Payer: Anthem Medicaid |
$20.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.53
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Cigna Commercial |
$50.57
|
| Rate for Payer: First Health Commercial |
$57.88
|
| Rate for Payer: Humana Commercial |
$51.79
|
| Rate for Payer: Humana KY Medicaid |
$20.95
|
| Rate for Payer: Kentucky WC Medicaid |
$21.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.62
|
| Rate for Payer: Ohio Health Group HMO |
$45.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.89
|
| Rate for Payer: PHCS Commercial |
$58.49
|
| Rate for Payer: United Healthcare All Payer |
$53.62
|
|
|
SUBOXONE 8MG/2MG TABLET COMB
|
Facility
|
IP
|
$60.93
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
25001897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$58.49 |
| Rate for Payer: Aetna Commercial |
$46.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.53
|
| Rate for Payer: Cash Price |
$30.46
|
| Rate for Payer: Cigna Commercial |
$50.57
|
| Rate for Payer: First Health Commercial |
$57.88
|
| Rate for Payer: Humana Commercial |
$51.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.62
|
| Rate for Payer: Ohio Health Group HMO |
$45.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.89
|
| Rate for Payer: PHCS Commercial |
$58.49
|
| Rate for Payer: United Healthcare All Payer |
$53.62
|
|
|
SUBSQ HOSPITAL CARE LEVEL 1
|
Professional
|
Both
|
$108.75
|
|
|
Service Code
|
HCPCS 99231
|
| Hospital Charge Code |
51000014
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Aetna Commercial |
$58.86
|
| Rate for Payer: Anthem Medicaid |
$25.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.75
|
| Rate for Payer: Cash Price |
$54.38
|
| Rate for Payer: Cash Price |
$54.38
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Healthspan PPO |
$43.76
|
| Rate for Payer: Humana Medicaid |
$25.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$52.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.41
|
| Rate for Payer: Molina Healthcare Passport |
$25.89
|
| Rate for Payer: Multiplan PHCS |
$65.25
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$76.12
|
| Rate for Payer: UHCCP Medicaid |
$38.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.15
|
|
|
SUBSQ HOSPITAL CARE LEVEL 1(P
|
Professional
|
Both
|
$108.75
|
|
|
Service Code
|
HCPCS 99231
|
| Hospital Charge Code |
510P0014
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Aetna Commercial |
$58.86
|
| Rate for Payer: Anthem Medicaid |
$25.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.75
|
| Rate for Payer: Cash Price |
$54.38
|
| Rate for Payer: Cash Price |
$54.38
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Healthspan PPO |
$43.76
|
| Rate for Payer: Humana Medicaid |
$25.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$52.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.41
|
| Rate for Payer: Molina Healthcare Passport |
$25.89
|
| Rate for Payer: Multiplan PHCS |
$65.25
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$76.12
|
| Rate for Payer: UHCCP Medicaid |
$38.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.15
|
|
|
SUBSQ HOSPITAL CARE LEVEL 2
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
HCPCS 99232
|
| Hospital Charge Code |
51000015
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Anthem Medicaid |
$42.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$110.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$97.57
|
| Rate for Payer: Healthspan PPO |
$78.48
|
| Rate for Payer: Humana Medicaid |
$42.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.08
|
| Rate for Payer: Molina Healthcare Passport |
$42.24
|
| Rate for Payer: Multiplan PHCS |
$66.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$77.00
|
| Rate for Payer: UHCCP Medicaid |
$38.50
|
| Rate for Payer: United Healthcare Non-Options |
$72.71
|
| Rate for Payer: United Healthcare Options |
$59.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.66
|
|
|
SUBSQ HOSPITAL CARE LEVEL 2(P
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
HCPCS 99232
|
| Hospital Charge Code |
510P0015
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Anthem Medicaid |
$42.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$110.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$97.57
|
| Rate for Payer: Healthspan PPO |
$78.48
|
| Rate for Payer: Humana Medicaid |
$42.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.08
|
| Rate for Payer: Molina Healthcare Passport |
$42.24
|
| Rate for Payer: Multiplan PHCS |
$66.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$77.00
|
| Rate for Payer: UHCCP Medicaid |
$38.50
|
| Rate for Payer: United Healthcare Non-Options |
$72.71
|
| Rate for Payer: United Healthcare Options |
$59.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.66
|
|
|
SUBSQ HOSPITAL CARE LEVEL 3
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 99233
|
| Hospital Charge Code |
51000016
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$151.33 |
| Rate for Payer: Aetna Commercial |
$151.33
|
| Rate for Payer: Anthem Medicaid |
$60.07
|
| 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: Cigna Commercial |
$139.46
|
| Rate for Payer: Healthspan PPO |
$112.49
|
| Rate for Payer: Humana Medicaid |
$60.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$136.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.27
|
| Rate for Payer: Molina Healthcare Passport |
$60.07
|
| 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
|
| Rate for Payer: United Healthcare Non-Options |
$104.22
|
| Rate for Payer: United Healthcare Options |
$85.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.67
|
|
|
SUBSQ HOSPITAL CARE LEVEL 3(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 99233
|
| Hospital Charge Code |
510P0016
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$151.33 |
| Rate for Payer: Aetna Commercial |
$151.33
|
| Rate for Payer: Anthem Medicaid |
$60.07
|
| 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: Cigna Commercial |
$139.46
|
| Rate for Payer: Healthspan PPO |
$112.49
|
| Rate for Payer: Humana Medicaid |
$60.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$136.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.27
|
| Rate for Payer: Molina Healthcare Passport |
$60.07
|
| 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
|
| Rate for Payer: United Healthcare Non-Options |
$104.22
|
| Rate for Payer: United Healthcare Options |
$85.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.67
|
|
|
SUBUTEX [1MG] 2MG EQUIV TAB
|
Facility
|
OP
|
$60.31
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$57.90 |
| Rate for Payer: Aetna Commercial |
$46.44
|
| Rate for Payer: Anthem Medicaid |
$20.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.04
|
| Rate for Payer: Cash Price |
$30.16
|
| Rate for Payer: Cigna Commercial |
$50.06
|
| Rate for Payer: First Health Commercial |
$57.29
|
| Rate for Payer: Humana Commercial |
$51.26
|
| Rate for Payer: Humana KY Medicaid |
$20.74
|
| Rate for Payer: Kentucky WC Medicaid |
$20.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.07
|
| Rate for Payer: Ohio Health Group HMO |
$45.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.70
|
| Rate for Payer: PHCS Commercial |
$57.90
|
| Rate for Payer: United Healthcare All Payer |
$53.07
|
|
|
SUBUTEX [1MG] 2MG EQUIV TAB
|
Facility
|
IP
|
$60.31
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$57.90 |
| Rate for Payer: Aetna Commercial |
$46.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.04
|
| Rate for Payer: Cash Price |
$30.16
|
| Rate for Payer: Cigna Commercial |
$50.06
|
| Rate for Payer: First Health Commercial |
$57.29
|
| Rate for Payer: Humana Commercial |
$51.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.07
|
| Rate for Payer: Ohio Health Group HMO |
$45.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.70
|
| Rate for Payer: PHCS Commercial |
$57.90
|
| Rate for Payer: United Healthcare All Payer |
$53.07
|
|
|
SUBUTEX [1 MG] 8MG EQUIV TAB
|
Facility
|
IP
|
$62.55
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$60.05 |
| Rate for Payer: Aetna Commercial |
$48.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.79
|
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Cigna Commercial |
$51.92
|
| Rate for Payer: First Health Commercial |
$59.42
|
| Rate for Payer: Humana Commercial |
$53.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.04
|
| Rate for Payer: Ohio Health Group HMO |
$46.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.39
|
| Rate for Payer: PHCS Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Payer |
$55.04
|
|
