|
COV5-11/23-24 PFIZER
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
77000091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$340.00
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Multiplan PHCS |
$204.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$238.00
|
| Rate for Payer: UHCCP Medicaid |
$119.00
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
77000091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.20
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.40
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
770T0091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem Medicaid |
$116.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.20
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Humana KY Medicaid |
$116.93
|
| Rate for Payer: Kentucky WC Medicaid |
$118.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$119.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.40
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
25004429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$332.16 |
| Rate for Payer: Aetna Commercial |
$266.42
|
| Rate for Payer: Anthem Medicaid |
$118.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$269.88
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$287.18
|
| Rate for Payer: First Health Commercial |
$328.70
|
| Rate for Payer: Humana Commercial |
$294.10
|
| Rate for Payer: Humana KY Medicaid |
$118.99
|
| Rate for Payer: Kentucky WC Medicaid |
$120.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$283.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$255.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$121.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$304.48
|
| Rate for Payer: Ohio Health Group HMO |
$259.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.26
|
| Rate for Payer: PHCS Commercial |
$332.16
|
| Rate for Payer: United Healthcare All Payer |
$304.48
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
770T0091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.20
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.40
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
COV6M-4YPFI23-24
|
Facility
|
IP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
770T0094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.66 |
| Max. Negotiated Rate |
$307.68 |
| Rate for Payer: Aetna Commercial |
$246.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.99
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Cigna Commercial |
$266.02
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.04
|
| Rate for Payer: Ohio Health Group HMO |
$240.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$307.68
|
| Rate for Payer: United Healthcare All Payer |
$282.04
|
|
|
COV6M-4YPFI23-24
|
Facility
|
OP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
770T0094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.66 |
| Max. Negotiated Rate |
$307.68 |
| Rate for Payer: Aetna Commercial |
$246.78
|
| Rate for Payer: Anthem Medicaid |
$110.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.99
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Cigna Commercial |
$266.02
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.42
|
| Rate for Payer: Humana KY Medicaid |
$110.22
|
| Rate for Payer: Kentucky WC Medicaid |
$111.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.04
|
| Rate for Payer: Ohio Health Group HMO |
$240.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$307.68
|
| Rate for Payer: United Healthcare All Payer |
$282.04
|
|
|
COV6M-4YPFI23-24
|
Professional
|
Both
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
77000094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.18 |
| Max. Negotiated Rate |
$320.50 |
| Rate for Payer: Buckeye Medicare Advantage |
$320.50
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Multiplan PHCS |
$192.30
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.35
|
| Rate for Payer: UHCCP Medicaid |
$112.18
|
|
|
COV6M-4YPFI23-24
|
Facility
|
IP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
77000094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.66 |
| Max. Negotiated Rate |
$307.68 |
| Rate for Payer: Aetna Commercial |
$246.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.99
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Cigna Commercial |
$266.02
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.04
|
| Rate for Payer: Ohio Health Group HMO |
$240.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$307.68
|
| Rate for Payer: United Healthcare All Payer |
$282.04
|
|
|
COV6M-4YPFI23-24
|
Facility
|
OP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
77000094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.66 |
| Max. Negotiated Rate |
$307.68 |
| Rate for Payer: Aetna Commercial |
$246.78
|
| Rate for Payer: Anthem Medicaid |
$110.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.99
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Cigna Commercial |
$266.02
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.42
|
| Rate for Payer: Humana KY Medicaid |
$110.22
|
| Rate for Payer: Kentucky WC Medicaid |
$111.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.04
|
| Rate for Payer: Ohio Health Group HMO |
$240.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$307.68
|
| Rate for Payer: United Healthcare All Payer |
$282.04
|
|
|
COVER LARYNGO-SHEATH 2.5*12.75
|
Facility
|
IP
|
$1,808.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.10 |
| Max. Negotiated Rate |
$1,736.16 |
| Rate for Payer: Aetna Commercial |
$1,392.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.63
|
| Rate for Payer: Cash Price |
$904.25
|
| Rate for Payer: Cigna Commercial |
$1,501.06
|
| Rate for Payer: First Health Commercial |
$1,718.08
|
| Rate for Payer: Humana Commercial |
$1,537.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,356.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.64
|
| Rate for Payer: PHCS Commercial |
$1,736.16
|
| Rate for Payer: United Healthcare All Payer |
$1,591.48
|
|
|
COVER LARYNGO-SHEATH 2.5*12.75
|
Facility
|
OP
|
$1,808.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.10 |
| Max. Negotiated Rate |
$1,736.16 |
| Rate for Payer: Aetna Commercial |
$1,392.54
|
| Rate for Payer: Anthem Medicaid |
$621.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.63
|
| Rate for Payer: Cash Price |
$904.25
|
| Rate for Payer: Cigna Commercial |
$1,501.06
|
| Rate for Payer: First Health Commercial |
$1,718.08
|
| Rate for Payer: Humana Commercial |
$1,537.22
|
| Rate for Payer: Humana KY Medicaid |
$621.94
|
| Rate for Payer: Kentucky WC Medicaid |
$628.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,356.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.64
|
| Rate for Payer: PHCS Commercial |
$1,736.16
|
| Rate for Payer: United Healthcare All Payer |
$1,591.48
|
|
|
COVIC12+PFI23-24
|
Facility
|
IP
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
77000092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.51 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Aetna Commercial |
$405.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.06
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Cigna Commercial |
$437.41
|
| Rate for Payer: First Health Commercial |
$500.65
|
| Rate for Payer: Humana Commercial |
$447.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$388.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$463.76
|
| Rate for Payer: Ohio Health Group HMO |
$395.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.37
|
| Rate for Payer: PHCS Commercial |
$505.92
|
| Rate for Payer: United Healthcare All Payer |
$463.76
|
|
|
COVIC12+PFI23-24
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
25004430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.59 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem Medicaid |
$186.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Humana KY Medicaid |
$186.74
|
| Rate for Payer: Kentucky WC Medicaid |
$188.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.33
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
COVIC12+PFI23-24
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
25004430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.59 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.33
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
COVIC12+PFI23-24
|
Facility
|
OP
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
77000092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.51 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Aetna Commercial |
$405.79
|
| Rate for Payer: Anthem Medicaid |
$181.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.06
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Cigna Commercial |
$437.41
|
| Rate for Payer: First Health Commercial |
$500.65
|
| Rate for Payer: Humana Commercial |
$447.95
|
| Rate for Payer: Humana KY Medicaid |
$181.24
|
| Rate for Payer: Kentucky WC Medicaid |
$183.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$388.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$184.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$463.76
|
| Rate for Payer: Ohio Health Group HMO |
$395.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.37
|
| Rate for Payer: PHCS Commercial |
$505.92
|
| Rate for Payer: United Healthcare All Payer |
$463.76
|
|
|
COVIC12+PFI23-24
|
Facility
|
IP
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
770T0092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.51 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Aetna Commercial |
$405.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.06
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Cigna Commercial |
$437.41
|
| Rate for Payer: First Health Commercial |
$500.65
|
| Rate for Payer: Humana Commercial |
$447.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$388.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$463.76
|
| Rate for Payer: Ohio Health Group HMO |
$395.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.37
|
| Rate for Payer: PHCS Commercial |
$505.92
|
| Rate for Payer: United Healthcare All Payer |
$463.76
|
|
|
COVIC12+PFI23-24
|
Facility
|
OP
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
770T0092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.51 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Aetna Commercial |
$405.79
|
| Rate for Payer: Anthem Medicaid |
$181.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.06
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Cigna Commercial |
$437.41
|
| Rate for Payer: First Health Commercial |
$500.65
|
| Rate for Payer: Humana Commercial |
$447.95
|
| Rate for Payer: Humana KY Medicaid |
$181.24
|
| Rate for Payer: Kentucky WC Medicaid |
$183.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$388.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$184.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$463.76
|
| Rate for Payer: Ohio Health Group HMO |
$395.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.37
|
| Rate for Payer: PHCS Commercial |
$505.92
|
| Rate for Payer: United Healthcare All Payer |
$463.76
|
|
|
COVIC12+PFI23-24
|
Professional
|
Both
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
77000092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$184.45 |
| Max. Negotiated Rate |
$527.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$527.00
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Multiplan PHCS |
$316.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$368.90
|
| Rate for Payer: UHCCP Medicaid |
$184.45
|
|
|
COVID19 50mcg(SPIKEVAX)Syringe
|
Facility
|
IP
|
$541.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
77000097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$519.84 |
| Rate for Payer: Aetna Commercial |
$416.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.37
|
| Rate for Payer: Cash Price |
$270.75
|
| Rate for Payer: Cigna Commercial |
$449.44
|
| Rate for Payer: First Health Commercial |
$514.42
|
| Rate for Payer: Humana Commercial |
$460.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.52
|
| Rate for Payer: Ohio Health Group HMO |
$406.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.86
|
| Rate for Payer: PHCS Commercial |
$519.84
|
| Rate for Payer: United Healthcare All Payer |
$476.52
|
|
|
COVID19 50mcg(SPIKEVAX)Syringe
|
Facility
|
IP
|
$541.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
770T0097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$519.84 |
| Rate for Payer: Aetna Commercial |
$416.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.37
|
| Rate for Payer: Cash Price |
$270.75
|
| Rate for Payer: Cigna Commercial |
$449.44
|
| Rate for Payer: First Health Commercial |
$514.42
|
| Rate for Payer: Humana Commercial |
$460.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.52
|
| Rate for Payer: Ohio Health Group HMO |
$406.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.86
|
| Rate for Payer: PHCS Commercial |
$519.84
|
| Rate for Payer: United Healthcare All Payer |
$476.52
|
|
|
COVID19 50mcg(SPIKEVAX)Syringe
|
Facility
|
OP
|
$541.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
77000097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$519.84 |
| Rate for Payer: Aetna Commercial |
$416.96
|
| Rate for Payer: Anthem Medicaid |
$186.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.37
|
| Rate for Payer: Cash Price |
$270.75
|
| Rate for Payer: Cigna Commercial |
$449.44
|
| Rate for Payer: First Health Commercial |
$514.42
|
| Rate for Payer: Humana Commercial |
$460.28
|
| Rate for Payer: Humana KY Medicaid |
$186.22
|
| Rate for Payer: Kentucky WC Medicaid |
$188.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.52
|
| Rate for Payer: Ohio Health Group HMO |
$406.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.86
|
| Rate for Payer: PHCS Commercial |
$519.84
|
| Rate for Payer: United Healthcare All Payer |
$476.52
|
|
|
COVID19 50mcg(SPIKEVAX)Syringe
|
Facility
|
OP
|
$541.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
770T0097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$519.84 |
| Rate for Payer: Aetna Commercial |
$416.96
|
| Rate for Payer: Anthem Medicaid |
$186.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.37
|
| Rate for Payer: Cash Price |
$270.75
|
| Rate for Payer: Cigna Commercial |
$449.44
|
| Rate for Payer: First Health Commercial |
$514.42
|
| Rate for Payer: Humana Commercial |
$460.28
|
| Rate for Payer: Humana KY Medicaid |
$186.22
|
| Rate for Payer: Kentucky WC Medicaid |
$188.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.52
|
| Rate for Payer: Ohio Health Group HMO |
$406.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.86
|
| Rate for Payer: PHCS Commercial |
$519.84
|
| Rate for Payer: United Healthcare All Payer |
$476.52
|
|
|
COVID19 50mcg(SPIKEVAX)Syringe
|
Professional
|
Both
|
$541.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
77000097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.52 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Buckeye Medicare Advantage |
$541.50
|
| Rate for Payer: Cash Price |
$270.75
|
| Rate for Payer: Multiplan PHCS |
$324.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$379.05
|
| Rate for Payer: UHCCP Medicaid |
$189.52
|
|
|
COVID-19 CONVALESCENT PLASMA
|
Facility
|
IP
|
$816.00
|
|
|
Service Code
|
HCPCS C9507
|
| Hospital Charge Code |
30002009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$106.08 |
| Max. Negotiated Rate |
$783.36 |
| Rate for Payer: Aetna Commercial |
$628.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cigna Commercial |
$677.28
|
| Rate for Payer: First Health Commercial |
$775.20
|
| Rate for Payer: Humana Commercial |
$693.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$669.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$602.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$718.08
|
| Rate for Payer: Ohio Health Group HMO |
$612.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.96
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
|
