|
IM GUIDE 8FR
|
Facility
|
OP
|
$811.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.50 |
| Max. Negotiated Rate |
$779.04 |
| Rate for Payer: Aetna Commercial |
$624.86
|
| Rate for Payer: Anthem Medicaid |
$279.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$632.97
|
| Rate for Payer: Cash Price |
$405.75
|
| Rate for Payer: Cigna Commercial |
$673.54
|
| Rate for Payer: First Health Commercial |
$770.92
|
| Rate for Payer: Humana Commercial |
$689.78
|
| Rate for Payer: Humana KY Medicaid |
$279.07
|
| Rate for Payer: Kentucky WC Medicaid |
$281.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$665.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$598.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$714.12
|
| Rate for Payer: Ohio Health Group HMO |
$608.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.56
|
| Rate for Payer: PHCS Commercial |
$779.04
|
| Rate for Payer: United Healthcare All Payer |
$714.12
|
|
|
IM INJECTION & SQ
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
94000003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.30
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.35
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
IM INJECTION & SQ
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
94000003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna Commercial |
$31.94
|
| Rate for Payer: Anthem Medicaid |
$18.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$85.00
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: Healthspan PPO |
$29.92
|
| Rate for Payer: Humana Medicaid |
$18.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.46
|
| Rate for Payer: Molina Healthcare Passport |
$18.10
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.50
|
| Rate for Payer: UHCCP Medicaid |
$29.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.28
|
|
|
IM INJECTION & SQ
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
94000003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$85.29 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem Medicaid |
$29.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$85.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.24
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Humana KY Medicaid |
$29.23
|
| Rate for Payer: Humana Medicare Advantage |
$60.92
|
| Rate for Payer: Kentucky WC Medicaid |
$29.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.35
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
IM INJECTION & SQ (T
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
940T0003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.30
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.35
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
IM INJECTION & SQ (T
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
940T0003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$85.29 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem Medicaid |
$29.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$85.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.24
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Humana KY Medicaid |
$29.23
|
| Rate for Payer: Humana Medicare Advantage |
$60.92
|
| Rate for Payer: Kentucky WC Medicaid |
$29.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.35
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
IMITREX (SUMATRIPTAN 25MG/1TAB
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 65862014636
|
| Hospital Charge Code |
25000772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
IMITREX (SUMATRIPTAN 25MG/1TAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 65862014636
|
| Hospital Charge Code |
25000772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
63600063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.55 |
| Max. Negotiated Rate |
$173.00 |
| Rate for Payer: Aetna Commercial |
$82.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$173.00
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Healthspan PPO |
$83.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.58
|
| Rate for Payer: Multiplan PHCS |
$103.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$121.10
|
| Rate for Payer: UHCCP Medicaid |
$60.55
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
63600063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
63600063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
25002378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
636T0063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
25002378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
IMITREX (SUMATRIPTAN) 6MG/.5ML
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
636T0063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
IMJUDO 1mg (25 mgSDV)
|
Facility
|
IP
|
$18,066.75
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,348.68 |
| Max. Negotiated Rate |
$17,344.08 |
| Rate for Payer: Aetna Commercial |
$13,911.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,092.06
|
| Rate for Payer: Cash Price |
$9,033.38
|
| Rate for Payer: Cigna Commercial |
$14,995.40
|
| Rate for Payer: First Health Commercial |
$17,163.41
|
| Rate for Payer: Humana Commercial |
$15,356.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,814.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,333.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,420.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,898.74
|
| Rate for Payer: Ohio Health Group HMO |
$13,550.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,613.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,348.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,600.69
|
| Rate for Payer: PHCS Commercial |
$17,344.08
|
| Rate for Payer: United Healthcare All Payer |
$15,898.74
|
|
|
IMJUDO 1mg (25 mgSDV)
|
Facility
|
OP
|
$18,066.75
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$136.09 |
| Max. Negotiated Rate |
$17,344.08 |
| Rate for Payer: Aetna Commercial |
$13,911.40
|
| Rate for Payer: Anthem Medicaid |
$6,213.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,092.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.73
|
| Rate for Payer: Cash Price |
$9,033.38
|
| Rate for Payer: Cash Price |
$9,033.38
|
| Rate for Payer: Cigna Commercial |
$14,995.40
|
| Rate for Payer: First Health Commercial |
$17,163.41
|
| Rate for Payer: Humana Commercial |
$15,356.74
|
| Rate for Payer: Humana KY Medicaid |
$6,213.16
|
| Rate for Payer: Humana Medicare Advantage |
$136.09
|
| Rate for Payer: Kentucky WC Medicaid |
$6,276.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,814.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,333.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,337.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,898.74
|
| Rate for Payer: Ohio Health Group HMO |
$13,550.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,613.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,348.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,600.69
|
| Rate for Payer: PHCS Commercial |
$17,344.08
|
| Rate for Payer: United Healthcare All Payer |
$15,898.74
|
|
|
IMJUDO 1mg (300 mgSDV)
|
Facility
|
IP
|
$216,801.00
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28,184.13 |
| Max. Negotiated Rate |
$208,128.96 |
| Rate for Payer: Aetna Commercial |
$166,936.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$169,104.78
|
| Rate for Payer: Cash Price |
$108,400.50
|
| Rate for Payer: Cigna Commercial |
$179,944.83
|
| Rate for Payer: First Health Commercial |
$205,960.95
|
| Rate for Payer: Humana Commercial |
$184,280.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$177,776.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$159,999.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65,040.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$190,784.88
|
| Rate for Payer: Ohio Health Group HMO |
$162,600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43,360.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,184.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,208.31
|
| Rate for Payer: PHCS Commercial |
$208,128.96
|
| Rate for Payer: United Healthcare All Payer |
$190,784.88
|
|
|
IMJUDO 1mg (300 mgSDV)
|
Facility
|
OP
|
$216,801.00
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
25004319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$136.09 |
| Max. Negotiated Rate |
$208,128.96 |
| Rate for Payer: Aetna Commercial |
$166,936.77
|
| Rate for Payer: Anthem Medicaid |
$74,557.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$169,104.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.73
|
| Rate for Payer: Cash Price |
$108,400.50
|
| Rate for Payer: Cash Price |
$108,400.50
|
| Rate for Payer: Cigna Commercial |
$179,944.83
|
| Rate for Payer: First Health Commercial |
$205,960.95
|
| Rate for Payer: Humana Commercial |
$184,280.85
|
| Rate for Payer: Humana KY Medicaid |
$74,557.86
|
| Rate for Payer: Humana Medicare Advantage |
$136.09
|
| Rate for Payer: Kentucky WC Medicaid |
$75,316.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$177,776.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$159,999.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$76,053.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$190,784.88
|
| Rate for Payer: Ohio Health Group HMO |
$162,600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43,360.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,184.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,208.31
|
| Rate for Payer: PHCS Commercial |
$208,128.96
|
| Rate for Payer: United Healthcare All Payer |
$190,784.88
|
|
|
IMLYGIC 10^6 PFU ML VIAL (1ML)
|
Facility
|
OP
|
$362.64
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.14 |
| Max. Negotiated Rate |
$348.13 |
| Rate for Payer: Aetna Commercial |
$279.23
|
| Rate for Payer: Anthem Medicaid |
$124.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$66.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$93.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.89
|
| Rate for Payer: Cash Price |
$181.32
|
| Rate for Payer: Cash Price |
$181.32
|
| Rate for Payer: Cigna Commercial |
$300.99
|
| Rate for Payer: First Health Commercial |
$344.51
|
| Rate for Payer: Humana Commercial |
$308.24
|
| Rate for Payer: Humana KY Medicaid |
$124.71
|
| Rate for Payer: Humana Medicare Advantage |
$66.59
|
| Rate for Payer: Kentucky WC Medicaid |
$125.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.12
|
| Rate for Payer: Ohio Health Group HMO |
$271.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.42
|
| Rate for Payer: PHCS Commercial |
$348.13
|
| Rate for Payer: United Healthcare All Payer |
$319.12
|
|
|
IMLYGIC 10^6 PFU ML VIAL (1ML)
|
Facility
|
IP
|
$362.64
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.14 |
| Max. Negotiated Rate |
$348.13 |
| Rate for Payer: Aetna Commercial |
$279.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.86
|
| Rate for Payer: Cash Price |
$181.32
|
| Rate for Payer: Cigna Commercial |
$300.99
|
| Rate for Payer: First Health Commercial |
$344.51
|
| Rate for Payer: Humana Commercial |
$308.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.12
|
| Rate for Payer: Ohio Health Group HMO |
$271.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.42
|
| Rate for Payer: PHCS Commercial |
$348.13
|
| Rate for Payer: United Healthcare All Payer |
$319.12
|
|
|
IMLYGIC 10^8 PFU ML VIAL (1ML)
|
Facility
|
IP
|
$36,259.56
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,713.74 |
| Max. Negotiated Rate |
$34,809.18 |
| Rate for Payer: Aetna Commercial |
$27,919.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,282.46
|
| Rate for Payer: Cash Price |
$18,129.78
|
| Rate for Payer: Cigna Commercial |
$30,095.43
|
| Rate for Payer: First Health Commercial |
$34,446.58
|
| Rate for Payer: Humana Commercial |
$30,820.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,732.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,759.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,877.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,908.41
|
| Rate for Payer: Ohio Health Group HMO |
$27,194.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,251.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,713.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,240.46
|
| Rate for Payer: PHCS Commercial |
$34,809.18
|
| Rate for Payer: United Healthcare All Payer |
$31,908.41
|
|
|
IMLYGIC 10^8 PFU ML VIAL (1ML)
|
Facility
|
OP
|
$36,259.56
|
|
|
Service Code
|
HCPCS J9325
|
| Hospital Charge Code |
25002680
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.59 |
| Max. Negotiated Rate |
$34,809.18 |
| Rate for Payer: Aetna Commercial |
$27,919.86
|
| Rate for Payer: Anthem Medicaid |
$12,469.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$66.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,282.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$93.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.89
|
| Rate for Payer: Cash Price |
$18,129.78
|
| Rate for Payer: Cash Price |
$18,129.78
|
| Rate for Payer: Cigna Commercial |
$30,095.43
|
| Rate for Payer: First Health Commercial |
$34,446.58
|
| Rate for Payer: Humana Commercial |
$30,820.63
|
| Rate for Payer: Humana KY Medicaid |
$12,469.66
|
| Rate for Payer: Humana Medicare Advantage |
$66.59
|
| Rate for Payer: Kentucky WC Medicaid |
$12,596.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,732.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,759.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,719.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,908.41
|
| Rate for Payer: Ohio Health Group HMO |
$27,194.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,251.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,713.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,240.46
|
| Rate for Payer: PHCS Commercial |
$34,809.18
|
| Rate for Payer: United Healthcare All Payer |
$31,908.41
|
|
|
IMME. INSERT OF BREAST PROSTHE
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19340
|
| Hospital Charge Code |
76100311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$453.06 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Aetna Commercial |
$600.32
|
| Rate for Payer: Anthem Medicaid |
$453.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$564.71
|
| Rate for Payer: Healthspan PPO |
$480.01
|
| Rate for Payer: Humana Medicaid |
$453.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,125.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.12
|
| Rate for Payer: Molina Healthcare Passport |
$453.06
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$457.59
|
|
|
IMME. INSERT OF BREAST PROSTHE
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19340
|
| Hospital Charge Code |
761P0311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$453.06 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Aetna Commercial |
$600.32
|
| Rate for Payer: Anthem Medicaid |
$453.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$564.71
|
| Rate for Payer: Healthspan PPO |
$480.01
|
| Rate for Payer: Humana Medicaid |
$453.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,125.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.12
|
| Rate for Payer: Molina Healthcare Passport |
$453.06
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$457.59
|
|
