|
COUPLER MINI MALE TO MALE 4MM
|
Facility
|
IP
|
$8,610.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,583.29 |
| Max. Negotiated Rate |
$8,266.52 |
| Rate for Payer: Aetna Commercial |
$6,630.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,716.55
|
| Rate for Payer: Cash Price |
$4,305.48
|
| Rate for Payer: Cigna Commercial |
$7,147.10
|
| Rate for Payer: First Health Commercial |
$8,180.41
|
| Rate for Payer: Humana Commercial |
$7,319.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,060.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,354.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,577.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,458.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,888.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,491.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,941.56
|
| Rate for Payer: PHCS Commercial |
$8,266.52
|
| Rate for Payer: United Healthcare All Payer |
$7,577.64
|
|
|
COUPLER MINI MALE TO MALE 6MM
|
Facility
|
IP
|
$8,610.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,583.29 |
| Max. Negotiated Rate |
$8,266.52 |
| Rate for Payer: Aetna Commercial |
$6,630.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,716.55
|
| Rate for Payer: Cash Price |
$4,305.48
|
| Rate for Payer: Cigna Commercial |
$7,147.10
|
| Rate for Payer: First Health Commercial |
$8,180.41
|
| Rate for Payer: Humana Commercial |
$7,319.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,060.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,354.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,577.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,458.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,888.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,491.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,941.56
|
| Rate for Payer: PHCS Commercial |
$8,266.52
|
| Rate for Payer: United Healthcare All Payer |
$7,577.64
|
|
|
COUPLER MINI MALE TO MALE 6MM
|
Facility
|
OP
|
$8,610.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,583.29 |
| Max. Negotiated Rate |
$8,266.52 |
| Rate for Payer: Aetna Commercial |
$6,630.44
|
| Rate for Payer: Anthem Medicaid |
$2,961.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,716.55
|
| Rate for Payer: Cash Price |
$4,305.48
|
| Rate for Payer: Cigna Commercial |
$7,147.10
|
| Rate for Payer: First Health Commercial |
$8,180.41
|
| Rate for Payer: Humana Commercial |
$7,319.32
|
| Rate for Payer: Humana KY Medicaid |
$2,961.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,991.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,060.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,354.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,020.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,577.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,458.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,888.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,491.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,941.56
|
| Rate for Payer: PHCS Commercial |
$8,266.52
|
| Rate for Payer: United Healthcare All Payer |
$7,577.64
|
|
|
COV5-11/23-24 PFIZER
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
77000091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.78 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Ambetter Exchange |
$87.78
|
| Rate for Payer: Anthem Medicaid |
$87.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$87.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.34
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Humana Medicaid |
$87.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$87.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$89.54
|
| Rate for Payer: Molina Healthcare Passport |
$87.78
|
| Rate for Payer: Multiplan PHCS |
$204.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$114.11
|
| Rate for Payer: UHCCP Medicaid |
$119.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$88.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$87.78
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
770T0091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.00 |
| 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 |
$272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.60
|
| 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 |
77000091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.00 |
| 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 |
$272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.60
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
77000091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.00 |
| 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 |
$272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.60
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
770T0091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.00 |
| 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 |
$272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.60
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
COV6M-4YPFI23-24
|
Facility
|
OP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
770T0094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.15 |
| 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 |
$266.01
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.43
|
| 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 |
$256.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.15
|
| 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 |
$96.15 |
| 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 |
$266.01
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.43
|
| 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 |
$256.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.15
|
| 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 |
$65.55 |
| Max. Negotiated Rate |
$192.30 |
| Rate for Payer: Ambetter Exchange |
$65.55
|
| Rate for Payer: Anthem Medicaid |
$65.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$65.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$65.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$78.66
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Humana Medicaid |
$65.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$65.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.86
|
| Rate for Payer: Molina Healthcare Passport |
$65.55
|
| Rate for Payer: Multiplan PHCS |
$192.30
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$85.22
|
| Rate for Payer: UHCCP Medicaid |
$112.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.21
|
| Rate for Payer: Wellcare Medicare Advantage |
$65.55
|
|
|
COV6M-4YPFI23-24
|
Facility
|
IP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
77000094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.15 |
| 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 |
$266.01
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.43
|
| 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 |
$256.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.15
|
| Rate for Payer: PHCS Commercial |
$307.68
|
| Rate for Payer: United Healthcare All Payer |
$282.04
|
|
|
COV6M-4YPFI23-24
|
Facility
|
IP
|
$320.50
|
|
|
Service Code
|
HCPCS 91318
|
| Hospital Charge Code |
770T0094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.15 |
| 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 |
$266.01
|
| Rate for Payer: First Health Commercial |
$304.48
|
| Rate for Payer: Humana Commercial |
$272.43
|
| 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 |
$256.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.15
|
| 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
|
$1,832.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
COVER LARYNGO-SHEATH 2.5*12.75
|
Facility
|
OP
|
$1,832.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem Medicaid |
$630.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Humana KY Medicaid |
$630.02
|
| Rate for Payer: Kentucky WC Medicaid |
$636.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$642.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
COVIC12+PFI23-24
|
Professional
|
Both
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
77000092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.89 |
| Max. Negotiated Rate |
$316.20 |
| Rate for Payer: Ambetter Exchange |
$155.90
|
| Rate for Payer: Anthem Medicaid |
$155.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$155.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.08
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Cash Price |
$263.50
|
| Rate for Payer: Humana Medicaid |
$155.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$155.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.01
|
| Rate for Payer: Molina Healthcare Passport |
$155.89
|
| Rate for Payer: Multiplan PHCS |
$316.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$202.67
|
| Rate for Payer: UHCCP Medicaid |
$184.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$155.90
|
|
|
COVIC12+PFI23-24
|
Facility
|
IP
|
$527.00
|
|
|
Service Code
|
HCPCS 91320
|
| Hospital Charge Code |
77000092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.10 |
| 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 |
$421.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.63
|
| 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 |
$158.10 |
| 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 |
$421.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.63
|
| 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 |
$158.10 |
| 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 |
$421.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.63
|
| 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 |
77000092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.10 |
| 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 |
$421.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.63
|
| Rate for Payer: PHCS Commercial |
$505.92
|
| Rate for Payer: United Healthcare All Payer |
$463.76
|
|
|
COVID-19 CONVALESCENT PLASMA
|
Facility
|
IP
|
$816.00
|
|
|
Service Code
|
HCPCS C9507
|
| Hospital Charge Code |
30002009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$244.80 |
| 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 |
$652.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$563.04
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
|
|
COVID-19 CONVALESCENT PLASMA
|
Facility
|
OP
|
$816.00
|
|
|
Service Code
|
HCPCS C9507
|
| Hospital Charge Code |
30002009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$280.62 |
| 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 |
$393.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$550.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$530.90
|
| 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 |
$393.26
|
| 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 |
$471.91
|
| 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 |
$652.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$563.04
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
|
|
COVID MODERNA 24-25 6M-11Y
|
Facility
|
IP
|
$555.71
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
770T0129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.71 |
| Max. Negotiated Rate |
$533.48 |
| Rate for Payer: Aetna Commercial |
$427.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$433.45
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Cigna Commercial |
$461.24
|
| Rate for Payer: First Health Commercial |
$527.92
|
| Rate for Payer: Humana Commercial |
$472.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$455.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$410.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$489.02
|
| Rate for Payer: Ohio Health Group HMO |
$416.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$483.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$383.44
|
| Rate for Payer: PHCS Commercial |
$533.48
|
| Rate for Payer: United Healthcare All Payer |
$489.02
|
|
|
COVID MODERNA 24-25 6M-11Y
|
Facility
|
IP
|
$555.71
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
636T0252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.71 |
| Max. Negotiated Rate |
$533.48 |
| Rate for Payer: Aetna Commercial |
$427.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$433.45
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Cigna Commercial |
$461.24
|
| Rate for Payer: First Health Commercial |
$527.92
|
| Rate for Payer: Humana Commercial |
$472.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$455.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$410.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$489.02
|
| Rate for Payer: Ohio Health Group HMO |
$416.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$483.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$383.44
|
| Rate for Payer: PHCS Commercial |
$533.48
|
| Rate for Payer: United Healthcare All Payer |
$489.02
|
|
|
COVID MODERNA 24-25 6M-11Y
|
Facility
|
IP
|
$555.71
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
63600252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.71 |
| Max. Negotiated Rate |
$533.48 |
| Rate for Payer: Aetna Commercial |
$427.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$433.45
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Cigna Commercial |
$461.24
|
| Rate for Payer: First Health Commercial |
$527.92
|
| Rate for Payer: Humana Commercial |
$472.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$455.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$410.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$489.02
|
| Rate for Payer: Ohio Health Group HMO |
$416.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$483.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$383.44
|
| Rate for Payer: PHCS Commercial |
$533.48
|
| Rate for Payer: United Healthcare All Payer |
$489.02
|
|
