|
COVID-19 CONVALESCENT PLASMA
|
Facility
|
OP
|
$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 Medicaid |
$280.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$444.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$622.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$600.53
|
| Rate for Payer: Cash Price |
$408.00
|
| 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: Humana KY Medicaid |
$280.62
|
| Rate for Payer: Humana Medicare Advantage |
$444.84
|
| Rate for Payer: Kentucky WC Medicaid |
$283.48
|
| 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 |
$533.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$286.25
|
| 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
|
|
|
COVID-19 SPEC COLLECT HOPD
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS C9803
|
| Hospital Charge Code |
30001801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Aetna Commercial |
$36.19
|
| Rate for Payer: Anthem Medicaid |
$16.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.74
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cigna Commercial |
$39.01
|
| Rate for Payer: First Health Commercial |
$44.65
|
| Rate for Payer: Humana Commercial |
$39.95
|
| Rate for Payer: Humana KY Medicaid |
$16.16
|
| Rate for Payer: Kentucky WC Medicaid |
$16.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$34.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$41.36
|
| Rate for Payer: Ohio Health Group HMO |
$35.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.57
|
| Rate for Payer: PHCS Commercial |
$45.12
|
| Rate for Payer: United Healthcare All Payer |
$41.36
|
|
|
COVID-19 SPEC COLLECT HOPD
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS C9803
|
| Hospital Charge Code |
30001801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Aetna Commercial |
$36.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.74
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cigna Commercial |
$39.01
|
| Rate for Payer: First Health Commercial |
$44.65
|
| Rate for Payer: Humana Commercial |
$39.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$34.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$41.36
|
| Rate for Payer: Ohio Health Group HMO |
$35.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.57
|
| Rate for Payer: PHCS Commercial |
$45.12
|
| Rate for Payer: United Healthcare All Payer |
$41.36
|
|
|
COVID-19 SPEC COLLECT HOPD
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
HCPCS C9803
|
| Hospital Charge Code |
30001832
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$35.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36.94
|
| Rate for Payer: Cash Price |
$23.00
|
| Rate for Payer: Cigna Commercial |
$38.18
|
| Rate for Payer: First Health Commercial |
$43.70
|
| Rate for Payer: Humana Commercial |
$39.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$37.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$40.48
|
| Rate for Payer: Ohio Health Group HMO |
$34.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.26
|
| Rate for Payer: PHCS Commercial |
$44.16
|
| Rate for Payer: United Healthcare All Payer |
$40.48
|
|
|
COVID-19 SPEC COLLECT HOPD
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
HCPCS C9803
|
| Hospital Charge Code |
30001832
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$35.42
|
| Rate for Payer: Anthem Medicaid |
$15.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36.94
|
| Rate for Payer: Cash Price |
$23.00
|
| Rate for Payer: Cigna Commercial |
$38.18
|
| Rate for Payer: First Health Commercial |
$43.70
|
| Rate for Payer: Humana Commercial |
$39.10
|
| Rate for Payer: Humana KY Medicaid |
$15.82
|
| Rate for Payer: Kentucky WC Medicaid |
$15.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$37.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$40.48
|
| Rate for Payer: Ohio Health Group HMO |
$34.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.26
|
| Rate for Payer: PHCS Commercial |
$44.16
|
| Rate for Payer: United Healthcare All Payer |
$40.48
|
|
|
COVID MODERNA 23-24 6M-11Y
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
77000129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.40
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
COVID MODERNA 23-24 6M-11Y
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
77000129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem Medicaid |
$185.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Humana KY Medicaid |
$185.71
|
| Rate for Payer: Kentucky WC Medicaid |
$187.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.40
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
COVID MODERNA 23-24 6M-11Y
|
Professional
|
Both
|
$540.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
77000129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$540.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$540.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Multiplan PHCS |
$324.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$378.00
|
| Rate for Payer: UHCCP Medicaid |
$189.00
|
|
|
COVID MODERNA 23-24 6M-11Y (T
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
770T0129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.40
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
COVID MODERNA 23-24 6M-11Y (T
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
770T0129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem Medicaid |
$185.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Humana KY Medicaid |
$185.71
|
| Rate for Payer: Kentucky WC Medicaid |
$187.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.40
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
IP
|
$557.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
25004435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.48 |
| Max. Negotiated Rate |
$535.20 |
| Rate for Payer: Aetna Commercial |
$429.28
|
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$434.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$278.75
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$462.72
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: First Health Commercial |
$529.62
|
| Rate for Payer: Humana Commercial |
$484.33
|
| Rate for Payer: Humana Commercial |
$473.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$457.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$467.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$411.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$420.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$490.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$418.12
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$111.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$176.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.82
|
| Rate for Payer: PHCS Commercial |
$535.20
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$490.60
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
OP
|
$557.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
25004435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.48 |
| Max. Negotiated Rate |
$535.20 |
| Rate for Payer: Aetna Commercial |
$429.28
|
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem Medicaid |
$191.72
|
| Rate for Payer: Anthem Medicaid |
$195.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$434.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$278.75
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: Cigna Commercial |
$462.72
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: First Health Commercial |
$529.62
|
| Rate for Payer: Humana Commercial |
$473.88
|
| Rate for Payer: Humana Commercial |
$484.33
|
| Rate for Payer: Humana KY Medicaid |
$191.72
|
| Rate for Payer: Humana KY Medicaid |
$195.95
|
| Rate for Payer: Kentucky WC Medicaid |
$197.95
|
| Rate for Payer: Kentucky WC Medicaid |
$193.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$457.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$467.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$420.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$411.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$195.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$490.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$418.12
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$111.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$176.64
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: PHCS Commercial |
$535.20
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
| Rate for Payer: United Healthcare All Payer |
$490.60
|
|
|
COWS MILK IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000854
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
COWS MILK IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000854
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
[C]OXYCINTIN(OXYCOD)80 MGTAB
|
Facility
|
IP
|
$90.48
|
|
|
Service Code
|
NDC 59011048020
|
| Hospital Charge Code |
25000113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$86.86 |
| Rate for Payer: Aetna Commercial |
$69.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.57
|
| Rate for Payer: Cash Price |
$45.24
|
| Rate for Payer: Cigna Commercial |
$75.10
|
| Rate for Payer: First Health Commercial |
$85.96
|
| Rate for Payer: Humana Commercial |
$76.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.62
|
| Rate for Payer: Ohio Health Group HMO |
$67.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.05
|
| Rate for Payer: PHCS Commercial |
$86.86
|
| Rate for Payer: United Healthcare All Payer |
$79.62
|
|
|
[C]OXYCINTIN(OXYCOD)80 MGTAB
|
Facility
|
OP
|
$90.48
|
|
|
Service Code
|
NDC 59011048020
|
| Hospital Charge Code |
25000113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$86.86 |
| Rate for Payer: Aetna Commercial |
$69.67
|
| Rate for Payer: Anthem Medicaid |
$31.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.57
|
| Rate for Payer: Cash Price |
$45.24
|
| Rate for Payer: Cigna Commercial |
$75.10
|
| Rate for Payer: First Health Commercial |
$85.96
|
| Rate for Payer: Humana Commercial |
$76.91
|
| Rate for Payer: Humana KY Medicaid |
$31.12
|
| Rate for Payer: Kentucky WC Medicaid |
$31.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.62
|
| Rate for Payer: Ohio Health Group HMO |
$67.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.05
|
| Rate for Payer: PHCS Commercial |
$86.86
|
| Rate for Payer: United Healthcare All Payer |
$79.62
|
|
|
[C]OXYCONTIN (10MG/1TAB)
|
Facility
|
OP
|
$65.33
|
|
|
Service Code
|
NDC 59011041010
|
| Hospital Charge Code |
25000066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$62.72 |
| Rate for Payer: Aetna Commercial |
$50.30
|
| Rate for Payer: Anthem Medicaid |
$22.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.96
|
| Rate for Payer: Cash Price |
$32.66
|
| Rate for Payer: Cigna Commercial |
$54.22
|
| Rate for Payer: First Health Commercial |
$62.06
|
| Rate for Payer: Humana Commercial |
$55.53
|
| Rate for Payer: Humana KY Medicaid |
$22.47
|
| Rate for Payer: Kentucky WC Medicaid |
$22.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.49
|
| Rate for Payer: Ohio Health Group HMO |
$49.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.25
|
| Rate for Payer: PHCS Commercial |
$62.72
|
| Rate for Payer: United Healthcare All Payer |
$57.49
|
|
|
[C]OXYCONTIN (10MG/1TAB)
|
Facility
|
IP
|
$65.33
|
|
|
Service Code
|
NDC 59011041010
|
| Hospital Charge Code |
25000066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$62.72 |
| Rate for Payer: Aetna Commercial |
$50.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.96
|
| Rate for Payer: Cash Price |
$32.66
|
| Rate for Payer: Cigna Commercial |
$54.22
|
| Rate for Payer: First Health Commercial |
$62.06
|
| Rate for Payer: Humana Commercial |
$55.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.49
|
| Rate for Payer: Ohio Health Group HMO |
$49.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.25
|
| Rate for Payer: PHCS Commercial |
$62.72
|
| Rate for Payer: United Healthcare All Payer |
$57.49
|
|
|
[C]OXYCONTIN (OXYCO 40MG/TAB)
|
Facility
|
IP
|
$77.03
|
|
|
Service Code
|
NDC 59011044010
|
| Hospital Charge Code |
25000079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.95 |
| Rate for Payer: Aetna Commercial |
$59.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.08
|
| Rate for Payer: Cash Price |
$38.52
|
| Rate for Payer: Cigna Commercial |
$63.93
|
| Rate for Payer: First Health Commercial |
$73.18
|
| Rate for Payer: Humana Commercial |
$65.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.79
|
| Rate for Payer: Ohio Health Group HMO |
$57.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$73.95
|
| Rate for Payer: United Healthcare All Payer |
$67.79
|
|
|
[C]OXYCONTIN (OXYCO 40MG/TAB)
|
Facility
|
OP
|
$77.03
|
|
|
Service Code
|
NDC 59011044010
|
| Hospital Charge Code |
25000079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.95 |
| Rate for Payer: Anthem Medicaid |
$26.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.08
|
| Rate for Payer: Cash Price |
$38.52
|
| Rate for Payer: Cigna Commercial |
$63.93
|
| Rate for Payer: First Health Commercial |
$73.18
|
| Rate for Payer: Humana Commercial |
$65.48
|
| Rate for Payer: Humana KY Medicaid |
$26.49
|
| Rate for Payer: Kentucky WC Medicaid |
$26.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.16
|
| Rate for Payer: Aetna Commercial |
$59.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.79
|
| Rate for Payer: Ohio Health Group HMO |
$57.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$73.95
|
| Rate for Payer: United Healthcare All Payer |
$67.79
|
|
|
COYOTE BALLOON 1.5*40*150 OTW
|
Facility
|
IP
|
$1,934.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.48 |
| Max. Negotiated Rate |
$1,857.12 |
| Rate for Payer: Aetna Commercial |
$1,489.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.91
|
| Rate for Payer: Cash Price |
$967.25
|
| Rate for Payer: Cigna Commercial |
$1,605.64
|
| Rate for Payer: First Health Commercial |
$1,837.78
|
| Rate for Payer: Humana Commercial |
$1,644.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$599.70
|
| Rate for Payer: PHCS Commercial |
$1,857.12
|
| Rate for Payer: United Healthcare All Payer |
$1,702.36
|
|
|
COYOTE BALLOON 1.5*40*150 OTW
|
Facility
|
OP
|
$1,934.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.48 |
| Max. Negotiated Rate |
$1,857.12 |
| Rate for Payer: Aetna Commercial |
$1,489.56
|
| Rate for Payer: Anthem Medicaid |
$665.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.91
|
| Rate for Payer: Cash Price |
$967.25
|
| Rate for Payer: Cigna Commercial |
$1,605.64
|
| Rate for Payer: First Health Commercial |
$1,837.78
|
| Rate for Payer: Humana Commercial |
$1,644.32
|
| Rate for Payer: Humana KY Medicaid |
$665.27
|
| Rate for Payer: Kentucky WC Medicaid |
$672.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$599.70
|
| Rate for Payer: PHCS Commercial |
$1,857.12
|
| Rate for Payer: United Healthcare All Payer |
$1,702.36
|
|
|
COYOTE BALLOON 1.5*40*90
|
Facility
|
IP
|
$1,934.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.48 |
| Max. Negotiated Rate |
$1,857.12 |
| Rate for Payer: Aetna Commercial |
$1,489.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.91
|
| Rate for Payer: Cash Price |
$967.25
|
| Rate for Payer: Cigna Commercial |
$1,605.64
|
| Rate for Payer: First Health Commercial |
$1,837.78
|
| Rate for Payer: Humana Commercial |
$1,644.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$599.70
|
| Rate for Payer: PHCS Commercial |
$1,857.12
|
| Rate for Payer: United Healthcare All Payer |
$1,702.36
|
|
|
COYOTE BALLOON 1.5*40*90
|
Facility
|
OP
|
$1,934.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.48 |
| Max. Negotiated Rate |
$1,857.12 |
| Rate for Payer: Aetna Commercial |
$1,489.56
|
| Rate for Payer: Anthem Medicaid |
$665.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.91
|
| Rate for Payer: Cash Price |
$967.25
|
| Rate for Payer: Cigna Commercial |
$1,605.64
|
| Rate for Payer: First Health Commercial |
$1,837.78
|
| Rate for Payer: Humana Commercial |
$1,644.32
|
| Rate for Payer: Humana KY Medicaid |
$665.27
|
| Rate for Payer: Kentucky WC Medicaid |
$672.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$599.70
|
| Rate for Payer: PHCS Commercial |
$1,857.12
|
| Rate for Payer: United Healthcare All Payer |
$1,702.36
|
|
|
COYOTE BALLOON 2*100*150 OTW
|
Facility
|
IP
|
$1,934.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.48 |
| Max. Negotiated Rate |
$1,857.12 |
| Rate for Payer: Aetna Commercial |
$1,489.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.91
|
| Rate for Payer: Cash Price |
$967.25
|
| Rate for Payer: Cigna Commercial |
$1,605.64
|
| Rate for Payer: First Health Commercial |
$1,837.78
|
| Rate for Payer: Humana Commercial |
$1,644.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$599.70
|
| Rate for Payer: PHCS Commercial |
$1,857.12
|
| Rate for Payer: United Healthcare All Payer |
$1,702.36
|
|
