|
SUBLATIVE LOWREYELIDS LASTX
|
Facility
|
OP
|
$250.00
|
|
| Hospital Charge Code |
22200170
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem Medicaid |
$85.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Humana KY Medicaid |
$85.97
|
| Rate for Payer: Kentucky WC Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
SUBLATIVE LOWREYELIDS LASTX
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200170
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
SUBLATIVE LOWREYELIDS-PP#1 50%
|
Professional
|
Both
|
$319.00
|
|
| Hospital Charge Code |
22200334
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$223.30 |
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$223.30
|
| Rate for Payer: UHCCP Medicaid |
$111.65
|
|
|
SUBLATVE FULFCE LSR PP#2/3 25%
|
Professional
|
Both
|
$255.00
|
|
| Hospital Charge Code |
22200450
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Multiplan PHCS |
$153.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.50
|
| Rate for Payer: UHCCP Medicaid |
$89.25
|
|
|
SUBLATVE FULFCE LSRTX PP#1 50%
|
Professional
|
Both
|
$510.00
|
|
| Hospital Charge Code |
22200333
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Multiplan PHCS |
$306.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$357.00
|
| Rate for Payer: UHCCP Medicaid |
$178.50
|
|
|
SUBLIMAZE 0.1 MG (1MG/20ML)
|
Facility
|
IP
|
$82.76
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.83 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna Commercial |
$63.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64.55
|
| Rate for Payer: Cash Price |
$41.38
|
| Rate for Payer: Cigna Commercial |
$68.69
|
| Rate for Payer: First Health Commercial |
$78.62
|
| Rate for Payer: Humana Commercial |
$70.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.83
|
| Rate for Payer: Ohio Health Group HMO |
$62.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.10
|
| Rate for Payer: PHCS Commercial |
$79.45
|
| Rate for Payer: United Healthcare All Payer |
$72.83
|
|
|
SUBLIMAZE 0.1 MG (1MG/20ML)
|
Facility
|
OP
|
$82.76
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.83 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna Commercial |
$63.73
|
| Rate for Payer: Anthem Medicaid |
$28.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64.55
|
| Rate for Payer: Cash Price |
$41.38
|
| Rate for Payer: Cigna Commercial |
$68.69
|
| Rate for Payer: First Health Commercial |
$78.62
|
| Rate for Payer: Humana Commercial |
$70.35
|
| Rate for Payer: Humana KY Medicaid |
$28.46
|
| Rate for Payer: Kentucky WC Medicaid |
$28.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.83
|
| Rate for Payer: Ohio Health Group HMO |
$62.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.10
|
| Rate for Payer: PHCS Commercial |
$79.45
|
| Rate for Payer: United Healthcare All Payer |
$72.83
|
|
|
SUBLIMAZE 100 MCG (250MCG/5ML)
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Anthem Medicaid |
$27.17
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem Medicaid |
$24.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.06
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cash Price |
$35.94
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: Cigna Commercial |
$59.65
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: First Health Commercial |
$68.28
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Humana Commercial |
$61.09
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Humana KY Medicaid |
$24.72
|
| Rate for Payer: Humana KY Medicaid |
$27.17
|
| Rate for Payer: Kentucky WC Medicaid |
$27.44
|
| Rate for Payer: Kentucky WC Medicaid |
$27.10
|
| Rate for Payer: Kentucky WC Medicaid |
$24.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group HMO |
$53.90
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.51
|
| Rate for Payer: PHCS Commercial |
$69.00
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
| Rate for Payer: United Healthcare All Payer |
$63.25
|
|
|
SUBLIMAZE 100 MCG (250MCG/5ML)
|
Facility
|
IP
|
$71.87
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.62
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cash Price |
$35.94
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: Cigna Commercial |
$59.65
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: First Health Commercial |
$68.28
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Humana Commercial |
$61.09
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$53.90
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.51
|
| Rate for Payer: PHCS Commercial |
$69.00
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
| Rate for Payer: United Healthcare All Payer |
$63.25
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
|
|
SUBLIMAZE 100 MCG/2ML AMPUL
|
Facility
|
IP
|
$74.54
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002377
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$71.56 |
| Rate for Payer: Aetna Commercial |
$57.40
|
| Rate for Payer: Aetna Commercial |
$58.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.70
|
| Rate for Payer: Cash Price |
$37.27
|
| Rate for Payer: Cash Price |
$38.27
|
| Rate for Payer: Cigna Commercial |
$61.87
|
| Rate for Payer: Cigna Commercial |
$63.53
|
| Rate for Payer: First Health Commercial |
$72.71
|
| Rate for Payer: First Health Commercial |
$70.81
|
| Rate for Payer: Humana Commercial |
$65.06
|
| Rate for Payer: Humana Commercial |
$63.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.36
|
| Rate for Payer: Ohio Health Group HMO |
$55.91
|
| Rate for Payer: Ohio Health Group HMO |
$57.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.43
|
| Rate for Payer: PHCS Commercial |
$71.56
|
| Rate for Payer: PHCS Commercial |
$73.48
|
| Rate for Payer: United Healthcare All Payer |
$65.60
|
| Rate for Payer: United Healthcare All Payer |
$67.36
|
|
|
SUBLIMAZE 100 MCG/2ML AMPUL
|
Facility
|
OP
|
$74.54
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002377
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$71.56 |
| Rate for Payer: Aetna Commercial |
$57.40
|
| Rate for Payer: Aetna Commercial |
$58.94
|
| Rate for Payer: Anthem Medicaid |
$25.63
|
| Rate for Payer: Anthem Medicaid |
$26.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.70
|
| Rate for Payer: Cash Price |
$37.27
|
| Rate for Payer: Cash Price |
$38.27
|
| Rate for Payer: Cigna Commercial |
$63.53
|
| Rate for Payer: Cigna Commercial |
$61.87
|
| Rate for Payer: First Health Commercial |
$72.71
|
| Rate for Payer: First Health Commercial |
$70.81
|
| Rate for Payer: Humana Commercial |
$63.36
|
| Rate for Payer: Humana Commercial |
$65.06
|
| Rate for Payer: Humana KY Medicaid |
$25.63
|
| Rate for Payer: Humana KY Medicaid |
$26.32
|
| Rate for Payer: Kentucky WC Medicaid |
$26.59
|
| Rate for Payer: Kentucky WC Medicaid |
$25.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.36
|
| Rate for Payer: Ohio Health Group HMO |
$55.91
|
| Rate for Payer: Ohio Health Group HMO |
$57.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.81
|
| Rate for Payer: PHCS Commercial |
$73.48
|
| Rate for Payer: PHCS Commercial |
$71.56
|
| Rate for Payer: United Healthcare All Payer |
$67.36
|
| Rate for Payer: United Healthcare All Payer |
$65.60
|
|
|
SUBLIMAZE 1MG/100 ML/NS DRIP
|
Facility
|
OP
|
$190.38
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25003500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.11 |
| Max. Negotiated Rate |
$182.76 |
| Rate for Payer: Aetna Commercial |
$146.59
|
| Rate for Payer: Anthem Medicaid |
$65.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.50
|
| Rate for Payer: Cash Price |
$95.19
|
| Rate for Payer: Cigna Commercial |
$158.02
|
| Rate for Payer: First Health Commercial |
$180.86
|
| Rate for Payer: Humana Commercial |
$161.82
|
| Rate for Payer: Humana KY Medicaid |
$65.47
|
| Rate for Payer: Kentucky WC Medicaid |
$66.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.53
|
| Rate for Payer: Ohio Health Group HMO |
$142.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.36
|
| Rate for Payer: PHCS Commercial |
$182.76
|
| Rate for Payer: United Healthcare All Payer |
$167.53
|
|
|
SUBLIMAZE 1MG/100 ML/NS DRIP
|
Facility
|
IP
|
$190.38
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25003500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.11 |
| Max. Negotiated Rate |
$182.76 |
| Rate for Payer: Aetna Commercial |
$146.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.50
|
| Rate for Payer: Cash Price |
$95.19
|
| Rate for Payer: Cigna Commercial |
$158.02
|
| Rate for Payer: First Health Commercial |
$180.86
|
| Rate for Payer: Humana Commercial |
$161.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.53
|
| Rate for Payer: Ohio Health Group HMO |
$142.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.36
|
| Rate for Payer: PHCS Commercial |
$182.76
|
| Rate for Payer: United Healthcare All Payer |
$167.53
|
|
|
SUBLIME FACE/NECK LASER TX
|
Professional
|
Both
|
$350.00
|
|
| Hospital Charge Code |
22200177
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
|
|
SUBLIME FACE/NECK LSR PP#1 50%
|
Professional
|
Both
|
$446.00
|
|
| Hospital Charge Code |
22200341
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$156.10 |
| Max. Negotiated Rate |
$312.20 |
| Rate for Payer: Cash Price |
$223.00
|
| Rate for Payer: Multiplan PHCS |
$267.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.20
|
| Rate for Payer: UHCCP Medicaid |
$156.10
|
|
|
SUBLIME FCE/NEC LSR PP#2/3 25%
|
Professional
|
Both
|
$223.00
|
|
| Hospital Charge Code |
22200457
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$156.10 |
| Rate for Payer: Cash Price |
$111.50
|
| Rate for Payer: Multiplan PHCS |
$133.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$156.10
|
| Rate for Payer: UHCCP Medicaid |
$78.05
|
|
|
SUBLI NASOLA CHE JOWL LASTX
|
Facility
|
OP
|
$325.00
|
|
| Hospital Charge Code |
22200176
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem Medicaid |
$111.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Humana KY Medicaid |
$111.77
|
| Rate for Payer: Kentucky WC Medicaid |
$112.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
SUBLI NASOLA CHE JOWL LASTX
|
Professional
|
Both
|
$325.00
|
|
| Hospital Charge Code |
22200176
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$227.50 |
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
|
|
SUBLI NASOLA CHE JOWL LASTX
|
Facility
|
IP
|
$325.00
|
|
| Hospital Charge Code |
22200176
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
SUBLI NASOLACHE JOWL PP#1 50%
|
Professional
|
Both
|
$414.00
|
|
| Hospital Charge Code |
22200340
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$144.90 |
| Max. Negotiated Rate |
$289.80 |
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Multiplan PHCS |
$248.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$289.80
|
| Rate for Payer: UHCCP Medicaid |
$144.90
|
|
|
SUBLI NASOLACHE JWL PP#2/3 25%
|
Professional
|
Both
|
$207.00
|
|
| Hospital Charge Code |
22200456
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$72.45 |
| Max. Negotiated Rate |
$144.90 |
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Multiplan PHCS |
$124.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.90
|
| Rate for Payer: UHCCP Medicaid |
$72.45
|
|
|
SUBLOCADE 100mg SYRINGE
|
Facility
|
OP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9991
|
| Hospital Charge Code |
25004127
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,976.55 |
| Max. Negotiated Rate |
$11,077.92 |
| Rate for Payer: Aetna Commercial |
$8,885.42
|
| Rate for Payer: Anthem Medicaid |
$3,968.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,976.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,000.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,767.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,668.34
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cigna Commercial |
$9,577.78
|
| Rate for Payer: First Health Commercial |
$10,962.52
|
| Rate for Payer: Humana Commercial |
$9,808.58
|
| Rate for Payer: Humana KY Medicaid |
$3,968.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,976.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,008.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,462.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,516.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,371.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,048.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,154.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,654.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,231.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,039.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,962.26
|
| Rate for Payer: PHCS Commercial |
$11,077.92
|
| Rate for Payer: United Healthcare All Payer |
$10,154.76
|
|
|
SUBLOCADE 100mg SYRINGE
|
Facility
|
IP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9991
|
| Hospital Charge Code |
25004127
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,461.85 |
| Max. Negotiated Rate |
$11,077.92 |
| Rate for Payer: Aetna Commercial |
$8,885.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,000.81
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cigna Commercial |
$9,577.78
|
| Rate for Payer: First Health Commercial |
$10,962.52
|
| Rate for Payer: Humana Commercial |
$9,808.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,462.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,516.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,461.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,154.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,654.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,231.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,039.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,962.26
|
| Rate for Payer: PHCS Commercial |
$11,077.92
|
| Rate for Payer: United Healthcare All Payer |
$10,154.76
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
IP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
25004128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,461.85 |
| Max. Negotiated Rate |
$11,077.92 |
| Rate for Payer: Aetna Commercial |
$8,885.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,000.81
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cigna Commercial |
$9,577.78
|
| Rate for Payer: First Health Commercial |
$10,962.52
|
| Rate for Payer: Humana Commercial |
$9,808.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,462.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,516.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,461.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,154.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,654.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,231.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,039.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,962.26
|
| Rate for Payer: PHCS Commercial |
$11,077.92
|
| Rate for Payer: United Healthcare All Payer |
$10,154.76
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
OP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
636T0156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,976.55 |
| Max. Negotiated Rate |
$11,077.92 |
| Rate for Payer: Aetna Commercial |
$8,885.42
|
| Rate for Payer: Anthem Medicaid |
$3,968.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,976.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,000.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,767.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,668.34
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cigna Commercial |
$9,577.78
|
| Rate for Payer: First Health Commercial |
$10,962.52
|
| Rate for Payer: Humana Commercial |
$9,808.58
|
| Rate for Payer: Humana KY Medicaid |
$3,968.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,976.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,008.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,462.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,516.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,371.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,048.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,154.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,654.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,231.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,039.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,962.26
|
| Rate for Payer: PHCS Commercial |
$11,077.92
|
| Rate for Payer: United Healthcare All Payer |
$10,154.76
|
|
