|
COVID MODERNA 24-25 6M-11Y
|
Facility
|
OP
|
$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 Medicaid |
$191.11
|
| 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: Humana KY Medicaid |
$191.11
|
| Rate for Payer: Kentucky WC Medicaid |
$193.05
|
| 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: Molina Healthcare Medicaid |
$194.94
|
| 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
|
Professional
|
Both
|
$555.71
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
77000129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.06 |
| Max. Negotiated Rate |
$333.43 |
| Rate for Payer: Ambetter Exchange |
$147.06
|
| Rate for Payer: Anthem Medicaid |
$147.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.47
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Humana Medicaid |
$147.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$150.00
|
| Rate for Payer: Molina Healthcare Passport |
$147.06
|
| Rate for Payer: Multiplan PHCS |
$333.43
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.18
|
| Rate for Payer: UHCCP Medicaid |
$194.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$148.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.06
|
|
|
COVID MODERNA 24-25 6M-11Y
|
Facility
|
OP
|
$555.71
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
77000129
|
|
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 Medicaid |
$191.11
|
| 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: Humana KY Medicaid |
$191.11
|
| Rate for Payer: Kentucky WC Medicaid |
$193.05
|
| 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: Molina Healthcare Medicaid |
$194.94
|
| 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
|
Professional
|
Both
|
$555.71
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
63600252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.06 |
| Max. Negotiated Rate |
$333.43 |
| Rate for Payer: Ambetter Exchange |
$147.06
|
| Rate for Payer: Anthem Medicaid |
$147.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.47
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Cash Price |
$277.86
|
| Rate for Payer: Humana Medicaid |
$147.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$150.00
|
| Rate for Payer: Molina Healthcare Passport |
$147.06
|
| Rate for Payer: Multiplan PHCS |
$333.43
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.18
|
| Rate for Payer: UHCCP Medicaid |
$194.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$148.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.06
|
|
|
COVID MODERNA 24-25 6M-11Y
|
Facility
|
OP
|
$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 Medicaid |
$191.11
|
| 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: Humana KY Medicaid |
$191.11
|
| Rate for Payer: Kentucky WC Medicaid |
$193.05
|
| 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: Molina Healthcare Medicaid |
$194.94
|
| 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
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
IP
|
$557.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
25004435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.25 |
| Max. Negotiated Rate |
$535.20 |
| Rate for Payer: Aetna Commercial |
$429.27
|
| 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 |
$462.73
|
| 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 |
$446.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$384.68
|
| 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
|
Professional
|
Both
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
63600251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.65 |
| Max. Negotiated Rate |
$341.88 |
| Rate for Payer: Ambetter Exchange |
$161.65
|
| Rate for Payer: Anthem Medicaid |
$161.65
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$193.98
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Humana Medicaid |
$161.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$161.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$164.88
|
| Rate for Payer: Molina Healthcare Passport |
$161.65
|
| Rate for Payer: Multiplan PHCS |
$341.88
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.15
|
| Rate for Payer: UHCCP Medicaid |
$199.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$163.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.65
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
OP
|
$557.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
25004435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.25 |
| Max. Negotiated Rate |
$535.20 |
| Rate for Payer: Aetna Commercial |
$429.27
|
| 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 |
$462.73
|
| 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 |
$446.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$384.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| 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
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Professional
|
Both
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
77000097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.65 |
| Max. Negotiated Rate |
$341.88 |
| Rate for Payer: Ambetter Exchange |
$161.65
|
| Rate for Payer: Anthem Medicaid |
$161.65
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$193.98
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Humana Medicaid |
$161.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$161.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$164.88
|
| Rate for Payer: Molina Healthcare Passport |
$161.65
|
| Rate for Payer: Multiplan PHCS |
$341.88
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.15
|
| Rate for Payer: UHCCP Medicaid |
$199.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$163.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.65
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
OP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
770T0097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem Medicaid |
$195.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| Rate for Payer: Humana KY Medicaid |
$195.95
|
| Rate for Payer: Kentucky WC Medicaid |
$197.95
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
IP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
77000097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
OP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
77000097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem Medicaid |
$195.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| Rate for Payer: Humana KY Medicaid |
$195.95
|
| Rate for Payer: Kentucky WC Medicaid |
$197.95
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
IP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
63600251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
IP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
770T0097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25
|
Facility
|
OP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
63600251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem Medicaid |
$195.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| Rate for Payer: Humana KY Medicaid |
$195.95
|
| Rate for Payer: Kentucky WC Medicaid |
$197.95
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25(T
|
Facility
|
OP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
636T0251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem Medicaid |
$195.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| Rate for Payer: Humana KY Medicaid |
$195.95
|
| Rate for Payer: Kentucky WC Medicaid |
$197.95
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COVID(MODERNA)SPIKEVAX 24/25(T
|
Facility
|
IP
|
$569.80
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
636T0251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.94 |
| Max. Negotiated Rate |
$547.01 |
| Rate for Payer: Aetna Commercial |
$438.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$444.44
|
| Rate for Payer: Cash Price |
$284.90
|
| Rate for Payer: Cigna Commercial |
$472.93
|
| Rate for Payer: First Health Commercial |
$541.31
|
| Rate for Payer: Humana Commercial |
$484.33
|
| 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: Molina Healthcare Benefit Exchange |
$170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$501.42
|
| Rate for Payer: Ohio Health Group HMO |
$427.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.16
|
| Rate for Payer: PHCS Commercial |
$547.01
|
| Rate for Payer: United Healthcare All Payer |
$501.42
|
|
|
COWS MILK IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000854
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
COWS MILK IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000854
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
[C]OXYCINTIN(OXYCOD)80 MGTAB
|
Facility
|
IP
|
$92.39
|
|
|
Service Code
|
NDC 59011048020
|
| Hospital Charge Code |
25000113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$88.69 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.06
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$76.68
|
| Rate for Payer: First Health Commercial |
$87.77
|
| Rate for Payer: Humana Commercial |
$78.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.30
|
| Rate for Payer: Ohio Health Group HMO |
$69.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.75
|
| Rate for Payer: PHCS Commercial |
$88.69
|
| Rate for Payer: United Healthcare All Payer |
$81.30
|
|
|
[C]OXYCINTIN(OXYCOD)80 MGTAB
|
Facility
|
OP
|
$92.39
|
|
|
Service Code
|
NDC 59011048020
|
| Hospital Charge Code |
25000113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$88.69 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Anthem Medicaid |
$31.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.06
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$76.68
|
| Rate for Payer: First Health Commercial |
$87.77
|
| Rate for Payer: Humana Commercial |
$78.53
|
| Rate for Payer: Humana KY Medicaid |
$31.77
|
| Rate for Payer: Kentucky WC Medicaid |
$32.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.30
|
| Rate for Payer: Ohio Health Group HMO |
$69.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.75
|
| Rate for Payer: PHCS Commercial |
$88.69
|
| Rate for Payer: United Healthcare All Payer |
$81.30
|
|
|
[C]OXYCONTIN (10MG/1TAB)
|
Facility
|
IP
|
$65.67
|
|
|
Service Code
|
NDC 59011041010
|
| Hospital Charge Code |
25000066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$63.04 |
| Rate for Payer: Aetna Commercial |
$50.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.22
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cigna Commercial |
$54.51
|
| Rate for Payer: First Health Commercial |
$62.39
|
| Rate for Payer: Humana Commercial |
$55.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.79
|
| Rate for Payer: Ohio Health Group HMO |
$49.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.31
|
| Rate for Payer: PHCS Commercial |
$63.04
|
| Rate for Payer: United Healthcare All Payer |
$57.79
|
|
|
[C]OXYCONTIN (10MG/1TAB)
|
Facility
|
OP
|
$65.67
|
|
|
Service Code
|
NDC 59011041010
|
| Hospital Charge Code |
25000066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$63.04 |
| Rate for Payer: Aetna Commercial |
$50.57
|
| Rate for Payer: Anthem Medicaid |
$22.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.22
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cigna Commercial |
$54.51
|
| Rate for Payer: First Health Commercial |
$62.39
|
| Rate for Payer: Humana Commercial |
$55.82
|
| Rate for Payer: Humana KY Medicaid |
$22.58
|
| Rate for Payer: Kentucky WC Medicaid |
$22.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.79
|
| Rate for Payer: Ohio Health Group HMO |
$49.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.31
|
| Rate for Payer: PHCS Commercial |
$63.04
|
| Rate for Payer: United Healthcare All Payer |
$57.79
|
|
