|
CCIIV3 VAC NO PRSV 0.5 ML IM
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
HCPCS 90661
|
| Hospital Charge Code |
77000023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$119.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$119.00
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.97
|
| Rate for Payer: Multiplan PHCS |
$71.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$83.30
|
| Rate for Payer: UHCCP Medicaid |
$41.65
|
|
|
CCIIV3 VAC NO PRSV 0.5 ML IM
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 90661
|
| Hospital Charge Code |
77000023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem Medicaid |
$40.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.82
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Humana KY Medicaid |
$40.92
|
| Rate for Payer: Kentucky WC Medicaid |
$41.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.89
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
CCIIV3 VAC NO PRSV 0.5 ML I(T
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 90661
|
| Hospital Charge Code |
770T0023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem Medicaid |
$40.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.82
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Humana KY Medicaid |
$40.92
|
| Rate for Payer: Kentucky WC Medicaid |
$41.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.89
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
CCIIV3 VAC NO PRSV 0.5 ML I(T
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 90661
|
| Hospital Charge Code |
770T0023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.82
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.89
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
[CC] MVASI 100MG/4ML VIAL
|
Facility
|
OP
|
$3,802.63
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
25003744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$3,650.52 |
| Rate for Payer: Aetna Commercial |
$2,928.03
|
| Rate for Payer: Anthem Medicaid |
$1,307.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,966.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.59
|
| Rate for Payer: Cash Price |
$1,901.32
|
| Rate for Payer: Cash Price |
$1,901.32
|
| Rate for Payer: Cigna Commercial |
$3,156.18
|
| Rate for Payer: First Health Commercial |
$3,612.50
|
| Rate for Payer: Humana Commercial |
$3,232.24
|
| Rate for Payer: Humana KY Medicaid |
$1,307.72
|
| Rate for Payer: Humana Medicare Advantage |
$25.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,321.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,118.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,806.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,346.31
|
| Rate for Payer: Ohio Health Group HMO |
$2,851.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,178.82
|
| Rate for Payer: PHCS Commercial |
$3,650.52
|
| Rate for Payer: United Healthcare All Payer |
$3,346.31
|
|
|
[CC] MVASI 100MG/4ML VIAL
|
Facility
|
IP
|
$3,802.63
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
25003744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$494.34 |
| Max. Negotiated Rate |
$3,650.52 |
| Rate for Payer: Aetna Commercial |
$2,928.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,966.05
|
| Rate for Payer: Cash Price |
$1,901.32
|
| Rate for Payer: Cigna Commercial |
$3,156.18
|
| Rate for Payer: First Health Commercial |
$3,612.50
|
| Rate for Payer: Humana Commercial |
$3,232.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,118.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,806.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,346.31
|
| Rate for Payer: Ohio Health Group HMO |
$2,851.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,178.82
|
| Rate for Payer: PHCS Commercial |
$3,650.52
|
| Rate for Payer: United Healthcare All Payer |
$3,346.31
|
|
|
[CC] MVASI 400 MG/16ML VIAL
|
Facility
|
OP
|
$15,210.35
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
25003745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$14,601.94 |
| Rate for Payer: Aetna Commercial |
$11,711.97
|
| Rate for Payer: Anthem Medicaid |
$5,230.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,864.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.59
|
| Rate for Payer: Cash Price |
$7,605.18
|
| Rate for Payer: Cash Price |
$7,605.18
|
| Rate for Payer: Cigna Commercial |
$12,624.59
|
| Rate for Payer: First Health Commercial |
$14,449.83
|
| Rate for Payer: Humana Commercial |
$12,928.80
|
| Rate for Payer: Humana KY Medicaid |
$5,230.84
|
| Rate for Payer: Humana Medicare Advantage |
$25.62
|
| Rate for Payer: Kentucky WC Medicaid |
$5,284.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,472.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,225.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,335.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,385.11
|
| Rate for Payer: Ohio Health Group HMO |
$11,407.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,042.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,977.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,715.21
|
| Rate for Payer: PHCS Commercial |
$14,601.94
|
| Rate for Payer: United Healthcare All Payer |
$13,385.11
|
|
|
[CC] MVASI 400 MG/16ML VIAL
|
Facility
|
IP
|
$15,210.35
|
|
|
Service Code
|
HCPCS Q5107
|
| Hospital Charge Code |
25003745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,977.35 |
| Max. Negotiated Rate |
$14,601.94 |
| Rate for Payer: Aetna Commercial |
$11,711.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,864.07
|
| Rate for Payer: Cash Price |
$7,605.18
|
| Rate for Payer: Cigna Commercial |
$12,624.59
|
| Rate for Payer: First Health Commercial |
$14,449.83
|
| Rate for Payer: Humana Commercial |
$12,928.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,472.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,225.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,563.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,385.11
|
| Rate for Payer: Ohio Health Group HMO |
$11,407.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,042.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,977.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,715.21
|
| Rate for Payer: PHCS Commercial |
$14,601.94
|
| Rate for Payer: United Healthcare All Payer |
$13,385.11
|
|
|
[C]CODEINE 30 MG TA 30MG/1TAB
|
Facility
|
IP
|
$60.78
|
|
|
Service Code
|
NDC 54024425
|
| Hospital Charge Code |
25000068
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$58.35 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.41
|
| Rate for Payer: Cash Price |
$30.39
|
| Rate for Payer: Cigna Commercial |
$50.45
|
| Rate for Payer: First Health Commercial |
$57.74
|
| Rate for Payer: Humana Commercial |
$51.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.49
|
| Rate for Payer: Ohio Health Group HMO |
$45.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.84
|
| Rate for Payer: PHCS Commercial |
$58.35
|
| Rate for Payer: United Healthcare All Payer |
$53.49
|
|
|
[C]CODEINE 30 MG TA 30MG/1TAB
|
Facility
|
OP
|
$60.78
|
|
|
Service Code
|
NDC 54024425
|
| Hospital Charge Code |
25000068
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$58.35 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Anthem Medicaid |
$20.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.41
|
| Rate for Payer: Cash Price |
$30.39
|
| Rate for Payer: Cigna Commercial |
$50.45
|
| Rate for Payer: First Health Commercial |
$57.74
|
| Rate for Payer: Humana Commercial |
$51.66
|
| Rate for Payer: Humana KY Medicaid |
$20.90
|
| Rate for Payer: Kentucky WC Medicaid |
$21.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.49
|
| Rate for Payer: Ohio Health Group HMO |
$45.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.84
|
| Rate for Payer: PHCS Commercial |
$58.35
|
| Rate for Payer: United Healthcare All Payer |
$53.49
|
|
|
CCP IGG
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 86200
|
| Hospital Charge Code |
30001001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.54
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$149.40
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Humana Commercial |
$153.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.40
|
| Rate for Payer: Ohio Health Group HMO |
$135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.80
|
| Rate for Payer: PHCS Commercial |
$172.80
|
| Rate for Payer: United Healthcare All Payer |
$158.40
|
|
|
CCP IGG
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 86200
|
| Hospital Charge Code |
30001001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Anthem Medicaid |
$12.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.95
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$149.40
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Humana Commercial |
$153.00
|
| Rate for Payer: Humana KY Medicaid |
$12.95
|
| Rate for Payer: Humana Medicare Advantage |
$12.95
|
| Rate for Payer: Kentucky WC Medicaid |
$13.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.40
|
| Rate for Payer: Ohio Health Group HMO |
$135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.80
|
| Rate for Payer: PHCS Commercial |
$172.80
|
| Rate for Payer: United Healthcare All Payer |
$158.40
|
|
|
[C]DEMEROL (MEPERIDI 50MG/1TAB
|
Facility
|
OP
|
$97.29
|
|
|
Service Code
|
NDC 42806005030
|
| Hospital Charge Code |
25000091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$93.40 |
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: Anthem Medicaid |
$33.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$75.89
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: First Health Commercial |
$92.43
|
| Rate for Payer: Humana Commercial |
$82.70
|
| Rate for Payer: Humana KY Medicaid |
$33.46
|
| Rate for Payer: Kentucky WC Medicaid |
$33.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$79.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$71.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.62
|
| Rate for Payer: Ohio Health Group HMO |
$72.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.16
|
| Rate for Payer: PHCS Commercial |
$93.40
|
| Rate for Payer: United Healthcare All Payer |
$85.62
|
|
|
[C]DEMEROL (MEPERIDI 50MG/1TAB
|
Facility
|
IP
|
$97.29
|
|
|
Service Code
|
NDC 42806005030
|
| Hospital Charge Code |
25000091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$93.40 |
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$75.89
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: First Health Commercial |
$92.43
|
| Rate for Payer: Humana Commercial |
$82.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$79.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$71.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.62
|
| Rate for Payer: Ohio Health Group HMO |
$72.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.16
|
| Rate for Payer: PHCS Commercial |
$93.40
|
| Rate for Payer: United Healthcare All Payer |
$85.62
|
|
|
C DIFFICILE AMPLIF DNA DETECT
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 87493
|
| Hospital Charge Code |
30001368
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem Medicaid |
$37.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$37.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$52.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.27
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Humana KY Medicaid |
$37.27
|
| Rate for Payer: Humana Medicare Advantage |
$37.27
|
| Rate for Payer: Kentucky WC Medicaid |
$37.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.85
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
C DIFFICILE AMPLIF DNA DETECT
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 87493
|
| Hospital Charge Code |
30001368
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.40
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.85
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
C DIFFICILE AMPLIF DNA DETECT
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
HCPCS 87493
|
| Hospital Charge Code |
30001368
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$80.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$135.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$36.44
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$81.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.50
|
| Rate for Payer: UHCCP Medicaid |
$47.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.36
|
|
|
C. DIFFICILE TOXIN STOOL
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS 87324
|
| Hospital Charge Code |
30001346
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: Aetna Commercial |
$9.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.64
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$9.96
|
| Rate for Payer: First Health Commercial |
$11.40
|
| Rate for Payer: Humana Commercial |
$10.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.56
|
| Rate for Payer: Ohio Health Group HMO |
$9.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.72
|
| Rate for Payer: PHCS Commercial |
$11.52
|
| Rate for Payer: United Healthcare All Payer |
$10.56
|
|
|
C. DIFFICILE TOXIN STOOL
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS 87324
|
| Hospital Charge Code |
30001346
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna Commercial |
$9.24
|
| Rate for Payer: Anthem Medicaid |
$11.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.98
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$9.96
|
| Rate for Payer: First Health Commercial |
$11.40
|
| Rate for Payer: Humana Commercial |
$10.20
|
| Rate for Payer: Humana KY Medicaid |
$11.98
|
| Rate for Payer: Humana Medicare Advantage |
$11.98
|
| Rate for Payer: Kentucky WC Medicaid |
$12.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.56
|
| Rate for Payer: Ohio Health Group HMO |
$9.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.72
|
| Rate for Payer: PHCS Commercial |
$11.52
|
| Rate for Payer: United Healthcare All Payer |
$10.56
|
|
|
[C]DILAUDID (HYDROMOR 2MG/1TAB
|
Facility
|
IP
|
$60.15
|
|
|
Service Code
|
NDC 406324301
|
| Hospital Charge Code |
25000092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.92
|
| Rate for Payer: First Health Commercial |
$57.14
|
| Rate for Payer: Humana Commercial |
$51.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.93
|
| Rate for Payer: Ohio Health Group HMO |
$45.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.65
|
| Rate for Payer: PHCS Commercial |
$57.74
|
| Rate for Payer: United Healthcare All Payer |
$52.93
|
|
|
[C]DILAUDID (HYDROMOR 2MG/1TAB
|
Facility
|
OP
|
$60.15
|
|
|
Service Code
|
NDC 406324301
|
| Hospital Charge Code |
25000092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Anthem Medicaid |
$20.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.92
|
| Rate for Payer: First Health Commercial |
$57.14
|
| Rate for Payer: Humana Commercial |
$51.13
|
| Rate for Payer: Humana KY Medicaid |
$20.69
|
| Rate for Payer: Kentucky WC Medicaid |
$20.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.32
|
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.93
|
| Rate for Payer: Ohio Health Group HMO |
$45.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.65
|
| Rate for Payer: PHCS Commercial |
$57.74
|
| Rate for Payer: United Healthcare All Payer |
$52.93
|
|
|
[C]DILAUDID (HYDROMOR 4MG/1TAB
|
Facility
|
OP
|
$60.17
|
|
|
Service Code
|
NDC 13107010801
|
| Hospital Charge Code |
25000093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.76 |
| Rate for Payer: Aetna Commercial |
$46.33
|
| Rate for Payer: Anthem Medicaid |
$20.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.93
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.94
|
| Rate for Payer: First Health Commercial |
$57.16
|
| Rate for Payer: Humana Commercial |
$51.14
|
| Rate for Payer: Humana KY Medicaid |
$20.69
|
| Rate for Payer: Kentucky WC Medicaid |
$20.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.95
|
| Rate for Payer: Ohio Health Group HMO |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.65
|
| Rate for Payer: PHCS Commercial |
$57.76
|
| Rate for Payer: United Healthcare All Payer |
$52.95
|
|
|
[C]DILAUDID (HYDROMOR 4MG/1TAB
|
Facility
|
IP
|
$60.17
|
|
|
Service Code
|
NDC 13107010801
|
| Hospital Charge Code |
25000093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.76 |
| Rate for Payer: Aetna Commercial |
$46.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.93
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.94
|
| Rate for Payer: First Health Commercial |
$57.16
|
| Rate for Payer: Humana Commercial |
$51.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.95
|
| Rate for Payer: Ohio Health Group HMO |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.65
|
| Rate for Payer: PHCS Commercial |
$57.76
|
| Rate for Payer: United Healthcare All Payer |
$52.95
|
|
|
CDL PHYSICAL
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 99455
|
| Hospital Charge Code |
22200666
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$85.00
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.03
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.50
|
| Rate for Payer: UHCCP Medicaid |
$29.75
|
|
|
[C]DUAGESIC (FENTAN 100MCG/1EA
|
Facility
|
IP
|
$87.56
|
|
|
Service Code
|
NDC 406900076
|
| Hospital Charge Code |
25000094
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.38 |
| Max. Negotiated Rate |
$84.06 |
| Rate for Payer: Aetna Commercial |
$67.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.30
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Cigna Commercial |
$72.67
|
| Rate for Payer: First Health Commercial |
$83.18
|
| Rate for Payer: Humana Commercial |
$74.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.05
|
| Rate for Payer: Ohio Health Group HMO |
$65.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.14
|
| Rate for Payer: PHCS Commercial |
$84.06
|
| Rate for Payer: United Healthcare All Payer |
$77.05
|
|
