|
SUBLOCADE 300mg SYRINGE
|
Facility
|
OP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
63600156
|
|
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 300mg SYRINGE
|
Facility
|
OP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
25004128
|
|
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 300mg SYRINGE
|
Professional
|
Both
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
63600156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,976.55 |
| Max. Negotiated Rate |
$6,923.70 |
| Rate for Payer: Ambetter Exchange |
$1,976.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,976.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,976.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,371.86
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Cash Price |
$5,769.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,462.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,976.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,976.55
|
| Rate for Payer: Multiplan PHCS |
$6,923.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,569.51
|
| Rate for Payer: UHCCP Medicaid |
$4,038.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,976.55
|
|
|
SUBLOCADE 300mg SYRINGE
|
Facility
|
IP
|
$11,539.50
|
|
|
Service Code
|
HCPCS Q9992
|
| Hospital Charge Code |
636T0156
|
|
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 |
63600156
|
|
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
|
|
|
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 |
$111.30 |
| 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 |
$111.30 |
| 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
|
$4,195.14
|
|
|
Service Code
|
CPT 30140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,996.53 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
|
|
SUBOXONE 2MG/ 0.5MG COMB
|
Facility
|
OP
|
$60.93
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
25001896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.28 |
| 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 |
$48.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.04
|
| Rate for Payer: PHCS Commercial |
$58.49
|
| Rate for Payer: United Healthcare All Payer |
$53.62
|
|
|
SUBOXONE 2MG/ 0.5MG COMB
|
Facility
|
IP
|
$60.93
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
25001896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.28 |
| 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 |
$48.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.04
|
| Rate for Payer: PHCS Commercial |
$58.49
|
| Rate for Payer: United Healthcare All Payer |
$53.62
|
|
|
SUBOXONE 8MG/2MG FILM
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
25004545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
SUBOXONE 8MG/2MG FILM
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
25004545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
SUBOXONE 8MG/2MG TABLET COMB
|
Facility
|
IP
|
$60.93
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
25001897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.28 |
| 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 |
$48.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.04
|
| 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 |
$18.28 |
| 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 |
$48.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.04
|
| 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 |
$65.25 |
| Rate for Payer: Aetna Commercial |
$58.86
|
| Rate for Payer: Ambetter Exchange |
$46.22
|
| Rate for Payer: Anthem Medicaid |
$25.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$46.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$46.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.46
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$46.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.22
|
| 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 |
$60.09
|
| Rate for Payer: UHCCP Medicaid |
$38.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$46.22
|
|
|
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 |
$65.25 |
| Rate for Payer: Aetna Commercial |
$58.86
|
| Rate for Payer: Ambetter Exchange |
$46.22
|
| Rate for Payer: Anthem Medicaid |
$25.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$46.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$46.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.46
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$46.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.22
|
| 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 |
$60.09
|
| Rate for Payer: UHCCP Medicaid |
$38.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$46.22
|
|
|
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 |
$105.57 |
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Ambetter Exchange |
$74.63
|
| Rate for Payer: Anthem Medicaid |
$42.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.56
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$74.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.63
|
| 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 |
$97.02
|
| 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
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.63
|
|
|
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 |
$105.57 |
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Ambetter Exchange |
$74.63
|
| Rate for Payer: Anthem Medicaid |
$42.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.56
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$74.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.63
|
| 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 |
$97.02
|
| 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
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.63
|
|
|
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: Ambetter Exchange |
$111.31
|
| Rate for Payer: Anthem Medicaid |
$60.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.57
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$111.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.31
|
| 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 |
$144.70
|
| 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
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.31
|
|
|
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: Ambetter Exchange |
$111.31
|
| Rate for Payer: Anthem Medicaid |
$60.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.57
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$111.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.31
|
| 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 |
$144.70
|
| 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
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.31
|
|
|
SUBUTEX [1MG] 2MG EQUIV TAB
|
Facility
|
OP
|
$60.53
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.16 |
| Max. Negotiated Rate |
$58.11 |
| Rate for Payer: Aetna Commercial |
$46.61
|
| Rate for Payer: Anthem Medicaid |
$20.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.21
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cigna Commercial |
$50.24
|
| Rate for Payer: First Health Commercial |
$57.50
|
| Rate for Payer: Humana Commercial |
$51.45
|
| Rate for Payer: Humana KY Medicaid |
$20.82
|
| Rate for Payer: Kentucky WC Medicaid |
$21.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.27
|
| Rate for Payer: Ohio Health Group HMO |
$45.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.77
|
| Rate for Payer: PHCS Commercial |
$58.11
|
| Rate for Payer: United Healthcare All Payer |
$53.27
|
|
|
SUBUTEX [1MG] 2MG EQUIV TAB
|
Facility
|
IP
|
$60.53
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.16 |
| Max. Negotiated Rate |
$58.11 |
| Rate for Payer: Aetna Commercial |
$46.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.21
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cigna Commercial |
$50.24
|
| Rate for Payer: First Health Commercial |
$57.50
|
| Rate for Payer: Humana Commercial |
$51.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.27
|
| Rate for Payer: Ohio Health Group HMO |
$45.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.77
|
| Rate for Payer: PHCS Commercial |
$58.11
|
| Rate for Payer: United Healthcare All Payer |
$53.27
|
|
|
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 |
$18.77 |
| 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 |
$18.77
|
| 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 |
$50.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.16
|
| Rate for Payer: PHCS Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Payer |
$55.04
|
|
|
SUBUTEX [1 MG] 8MG EQUIV TAB
|
Facility
|
OP
|
$62.55
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$60.05 |
| Rate for Payer: Aetna Commercial |
$48.16
|
| Rate for Payer: Anthem Medicaid |
$21.51
|
| 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: Humana KY Medicaid |
$21.51
|
| Rate for Payer: Kentucky WC Medicaid |
$21.73
|
| 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 |
$18.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.94
|
| 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 |
$50.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.16
|
| Rate for Payer: PHCS Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Payer |
$55.04
|
|
|
SUCTION LIPECTOMY HEAD&NECK
|
Facility
|
IP
|
$7,447.92
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
76100228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,234.38 |
| Max. Negotiated Rate |
$7,150.00 |
| Rate for Payer: Aetna Commercial |
$5,734.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,809.38
|
| Rate for Payer: Cash Price |
$3,723.96
|
| Rate for Payer: Cigna Commercial |
$6,181.77
|
| Rate for Payer: First Health Commercial |
$7,075.52
|
| Rate for Payer: Humana Commercial |
$6,330.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,107.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,496.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,554.17
|
| Rate for Payer: Ohio Health Group HMO |
$5,585.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,958.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,479.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,139.06
|
| Rate for Payer: PHCS Commercial |
$7,150.00
|
| Rate for Payer: United Healthcare All Payer |
$6,554.17
|
|
