|
IMRT PLAN(T
|
Facility
|
OP
|
$5,850.00
|
|
|
Service Code
|
HCPCS 77301
|
| Hospital Charge Code |
333T0007
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$760.50 |
| Max. Negotiated Rate |
$5,616.00 |
| Rate for Payer: Aetna Commercial |
$4,504.50
|
| Rate for Payer: Anthem Medicaid |
$2,011.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,198.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,563.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,677.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,617.60
|
| Rate for Payer: Cash Price |
$2,925.00
|
| Rate for Payer: Cash Price |
$2,925.00
|
| Rate for Payer: Cigna Commercial |
$4,855.50
|
| Rate for Payer: First Health Commercial |
$5,557.50
|
| Rate for Payer: Humana Commercial |
$4,972.50
|
| Rate for Payer: Humana KY Medicaid |
$2,011.82
|
| Rate for Payer: Humana Medicare Advantage |
$1,198.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,032.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,797.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,317.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,437.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,052.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,148.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,813.50
|
| Rate for Payer: PHCS Commercial |
$5,616.00
|
| Rate for Payer: United Healthcare All Payer |
$5,148.00
|
|
|
IMRT PLAN(T
|
Facility
|
IP
|
$5,850.00
|
|
|
Service Code
|
HCPCS 77301
|
| Hospital Charge Code |
333T0007
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$760.50 |
| Max. Negotiated Rate |
$5,616.00 |
| Rate for Payer: Aetna Commercial |
$4,504.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,563.00
|
| Rate for Payer: Cash Price |
$2,925.00
|
| Rate for Payer: Cigna Commercial |
$4,855.50
|
| Rate for Payer: First Health Commercial |
$5,557.50
|
| Rate for Payer: Humana Commercial |
$4,972.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,797.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,317.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,755.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,148.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,813.50
|
| Rate for Payer: PHCS Commercial |
$5,616.00
|
| Rate for Payer: United Healthcare All Payer |
$5,148.00
|
|
|
IMRT SIMPLE DELIVERY
|
Facility
|
OP
|
$1,552.00
|
|
|
Service Code
|
HCPCS 77385
|
| Hospital Charge Code |
33300021
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$201.76 |
| Max. Negotiated Rate |
$1,489.92 |
| Rate for Payer: Aetna Commercial |
$1,195.04
|
| Rate for Payer: Anthem Medicaid |
$533.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$509.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,210.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$712.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$687.22
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,288.16
|
| Rate for Payer: First Health Commercial |
$1,474.40
|
| Rate for Payer: Humana Commercial |
$1,319.20
|
| Rate for Payer: Humana KY Medicaid |
$533.73
|
| Rate for Payer: Humana Medicare Advantage |
$509.05
|
| Rate for Payer: Kentucky WC Medicaid |
$539.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,272.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,145.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$610.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$544.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,365.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,164.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$310.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$481.12
|
| Rate for Payer: PHCS Commercial |
$1,489.92
|
| Rate for Payer: United Healthcare All Payer |
$1,365.76
|
|
|
IMRT SIMPLE DELIVERY
|
Facility
|
IP
|
$1,552.00
|
|
|
Service Code
|
HCPCS 77385
|
| Hospital Charge Code |
33300021
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$201.76 |
| Max. Negotiated Rate |
$1,489.92 |
| Rate for Payer: Aetna Commercial |
$1,195.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,210.56
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,288.16
|
| Rate for Payer: First Health Commercial |
$1,474.40
|
| Rate for Payer: Humana Commercial |
$1,319.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,272.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,145.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$465.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,365.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,164.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$310.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$481.12
|
| Rate for Payer: PHCS Commercial |
$1,489.92
|
| Rate for Payer: United Healthcare All Payer |
$1,365.76
|
|
|
IM/SQ INJECTION
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
26000008
|
|
Hospital Revenue Code
|
260
|
| 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/SQ INJECTION
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
26000008
|
|
Hospital Revenue Code
|
260
|
| 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/SQ INJECTION
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
26000008
|
|
Hospital Revenue Code
|
260
|
| 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/SQ INJECTION(T
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
260T0008
|
|
Hospital Revenue Code
|
260
|
| 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/SQ INJECTION(T
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
260T0008
|
|
Hospital Revenue Code
|
260
|
| 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
|
|
|
IMT 5FR
|
Facility
|
IP
|
$170.68
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.19 |
| Max. Negotiated Rate |
$163.85 |
| Rate for Payer: Aetna Commercial |
$131.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$133.13
|
| Rate for Payer: Cash Price |
$85.34
|
| Rate for Payer: Cigna Commercial |
$141.66
|
| Rate for Payer: First Health Commercial |
$162.15
|
| Rate for Payer: Humana Commercial |
$145.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$139.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$125.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$150.20
|
| Rate for Payer: Ohio Health Group HMO |
$128.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.91
|
| Rate for Payer: PHCS Commercial |
$163.85
|
| Rate for Payer: United Healthcare All Payer |
$150.20
|
|
|
IMT 5FR
|
Facility
|
OP
|
$170.68
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.19 |
| Max. Negotiated Rate |
$163.85 |
| Rate for Payer: Aetna Commercial |
$131.42
|
| Rate for Payer: Anthem Medicaid |
$58.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$133.13
|
| Rate for Payer: Cash Price |
$85.34
|
| Rate for Payer: Cigna Commercial |
$141.66
|
| Rate for Payer: First Health Commercial |
$162.15
|
| Rate for Payer: Humana Commercial |
$145.08
|
| Rate for Payer: Humana KY Medicaid |
$58.70
|
| Rate for Payer: Kentucky WC Medicaid |
$59.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$139.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$125.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$59.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$150.20
|
| Rate for Payer: Ohio Health Group HMO |
$128.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.91
|
| Rate for Payer: PHCS Commercial |
$163.85
|
| Rate for Payer: United Healthcare All Payer |
$150.20
|
|
|
IMT CATH 5FR
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
IMT CATH 5FR
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
IMURAN (AZATHIOPRINE 50MG/1TAB
|
Facility
|
OP
|
$4.88
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
25002491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
IMURAN (AZATHIOPRINE 50MG/1TAB
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
25002491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
IN111 CAPROMAB
|
Facility
|
IP
|
$2,967.00
|
|
|
Service Code
|
HCPCS A9507
|
| Hospital Charge Code |
34000050
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$385.71 |
| Max. Negotiated Rate |
$2,848.32 |
| Rate for Payer: Aetna Commercial |
$2,284.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,314.26
|
| Rate for Payer: Cash Price |
$1,483.50
|
| Rate for Payer: Cigna Commercial |
$2,462.61
|
| Rate for Payer: First Health Commercial |
$2,818.65
|
| Rate for Payer: Humana Commercial |
$2,521.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,432.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,189.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$890.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,610.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,225.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$385.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$919.77
|
| Rate for Payer: PHCS Commercial |
$2,848.32
|
| Rate for Payer: United Healthcare All Payer |
$2,610.96
|
|
|
IN111 CAPROMAB
|
Facility
|
OP
|
$2,967.00
|
|
|
Service Code
|
HCPCS A9507
|
| Hospital Charge Code |
34000050
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$385.71 |
| Max. Negotiated Rate |
$2,848.32 |
| Rate for Payer: Aetna Commercial |
$2,284.59
|
| Rate for Payer: Anthem Medicaid |
$1,020.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,314.26
|
| Rate for Payer: Cash Price |
$1,483.50
|
| Rate for Payer: Cigna Commercial |
$2,462.61
|
| Rate for Payer: First Health Commercial |
$2,818.65
|
| Rate for Payer: Humana Commercial |
$2,521.95
|
| Rate for Payer: Humana KY Medicaid |
$1,020.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,030.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,432.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,189.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$890.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,040.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,610.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,225.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$385.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$919.77
|
| Rate for Payer: PHCS Commercial |
$2,848.32
|
| Rate for Payer: United Healthcare All Payer |
$2,610.96
|
|
|
IN111 IBRITUMOMAB, DX
|
Facility
|
OP
|
$3,804.00
|
|
|
Service Code
|
HCPCS A9542
|
| Hospital Charge Code |
34000057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$494.52 |
| Max. Negotiated Rate |
$3,651.84 |
| Rate for Payer: Aetna Commercial |
$2,929.08
|
| Rate for Payer: Anthem Medicaid |
$1,308.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,967.12
|
| Rate for Payer: Cash Price |
$1,902.00
|
| Rate for Payer: Cigna Commercial |
$3,157.32
|
| Rate for Payer: First Health Commercial |
$3,613.80
|
| Rate for Payer: Humana Commercial |
$3,233.40
|
| Rate for Payer: Humana KY Medicaid |
$1,308.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,321.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,119.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,807.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,141.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,334.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,347.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,853.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,179.24
|
| Rate for Payer: PHCS Commercial |
$3,651.84
|
| Rate for Payer: United Healthcare All Payer |
$3,347.52
|
|
|
IN111 IBRITUMOMAB, DX
|
Facility
|
IP
|
$3,804.00
|
|
|
Service Code
|
HCPCS A9542
|
| Hospital Charge Code |
34000057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$494.52 |
| Max. Negotiated Rate |
$3,651.84 |
| Rate for Payer: Aetna Commercial |
$2,929.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,967.12
|
| Rate for Payer: Cash Price |
$1,902.00
|
| Rate for Payer: Cigna Commercial |
$3,157.32
|
| Rate for Payer: First Health Commercial |
$3,613.80
|
| Rate for Payer: Humana Commercial |
$3,233.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,119.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,807.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,141.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,347.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,853.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,179.24
|
| Rate for Payer: PHCS Commercial |
$3,651.84
|
| Rate for Payer: United Healthcare All Payer |
$3,347.52
|
|
|
IN 111 OXYQUINOLINE PER 0.5MCI
|
Facility
|
IP
|
$1,651.00
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
34000059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$214.63 |
| Max. Negotiated Rate |
$1,584.96 |
| Rate for Payer: Aetna Commercial |
$1,271.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.78
|
| Rate for Payer: Cash Price |
$825.50
|
| Rate for Payer: Cigna Commercial |
$1,370.33
|
| Rate for Payer: First Health Commercial |
$1,568.45
|
| Rate for Payer: Humana Commercial |
$1,403.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,353.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,218.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$495.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,452.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,238.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.81
|
| Rate for Payer: PHCS Commercial |
$1,584.96
|
| Rate for Payer: United Healthcare All Payer |
$1,452.88
|
|
|
IN 111 OXYQUINOLINE PER 0.5MCI
|
Facility
|
OP
|
$1,651.00
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
34000059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$214.63 |
| Max. Negotiated Rate |
$1,584.96 |
| Rate for Payer: Aetna Commercial |
$1,271.27
|
| Rate for Payer: Anthem Medicaid |
$567.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.78
|
| Rate for Payer: Cash Price |
$825.50
|
| Rate for Payer: Cigna Commercial |
$1,370.33
|
| Rate for Payer: First Health Commercial |
$1,568.45
|
| Rate for Payer: Humana Commercial |
$1,403.35
|
| Rate for Payer: Humana KY Medicaid |
$567.78
|
| Rate for Payer: Kentucky WC Medicaid |
$573.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,353.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,218.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$495.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$579.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,452.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,238.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.81
|
| Rate for Payer: PHCS Commercial |
$1,584.96
|
| Rate for Payer: United Healthcare All Payer |
$1,452.88
|
|
|
IN 111 OXYQUINOLINE PER 0.5MCI
|
Facility
|
OP
|
$1,651.00
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
340T0059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$214.63 |
| Max. Negotiated Rate |
$1,584.96 |
| Rate for Payer: Aetna Commercial |
$1,271.27
|
| Rate for Payer: Anthem Medicaid |
$567.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.78
|
| Rate for Payer: Cash Price |
$825.50
|
| Rate for Payer: Cigna Commercial |
$1,370.33
|
| Rate for Payer: First Health Commercial |
$1,568.45
|
| Rate for Payer: Humana Commercial |
$1,403.35
|
| Rate for Payer: Humana KY Medicaid |
$567.78
|
| Rate for Payer: Kentucky WC Medicaid |
$573.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,353.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,218.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$495.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$579.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,452.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,238.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.81
|
| Rate for Payer: PHCS Commercial |
$1,584.96
|
| Rate for Payer: United Healthcare All Payer |
$1,452.88
|
|
|
IN 111 OXYQUINOLINE PER 0.5MCI
|
Facility
|
IP
|
$1,651.00
|
|
|
Service Code
|
HCPCS A9547
|
| Hospital Charge Code |
340T0059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$214.63 |
| Max. Negotiated Rate |
$1,584.96 |
| Rate for Payer: Aetna Commercial |
$1,271.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.78
|
| Rate for Payer: Cash Price |
$825.50
|
| Rate for Payer: Cigna Commercial |
$1,370.33
|
| Rate for Payer: First Health Commercial |
$1,568.45
|
| Rate for Payer: Humana Commercial |
$1,403.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,353.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,218.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$495.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,452.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,238.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.81
|
| Rate for Payer: PHCS Commercial |
$1,584.96
|
| Rate for Payer: United Healthcare All Payer |
$1,452.88
|
|
|
IN 111 PENETATE PER 0.5 MCI
|
Facility
|
IP
|
$1,267.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
34000060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$164.71 |
| Max. Negotiated Rate |
$1,216.32 |
| Rate for Payer: Aetna Commercial |
$975.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$988.26
|
| Rate for Payer: Cash Price |
$633.50
|
| Rate for Payer: Cigna Commercial |
$1,051.61
|
| Rate for Payer: First Health Commercial |
$1,203.65
|
| Rate for Payer: Humana Commercial |
$1,076.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,038.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$935.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$380.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,114.96
|
| Rate for Payer: Ohio Health Group HMO |
$950.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$253.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$392.77
|
| Rate for Payer: PHCS Commercial |
$1,216.32
|
| Rate for Payer: United Healthcare All Payer |
$1,114.96
|
|
|
IN 111 PENETATE PER 0.5 MCI
|
Facility
|
OP
|
$1,267.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
34000060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$164.71 |
| Max. Negotiated Rate |
$1,216.32 |
| Rate for Payer: Aetna Commercial |
$975.59
|
| Rate for Payer: Anthem Medicaid |
$435.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$988.26
|
| Rate for Payer: Cash Price |
$633.50
|
| Rate for Payer: Cigna Commercial |
$1,051.61
|
| Rate for Payer: First Health Commercial |
$1,203.65
|
| Rate for Payer: Humana Commercial |
$1,076.95
|
| Rate for Payer: Humana KY Medicaid |
$435.72
|
| Rate for Payer: Kentucky WC Medicaid |
$440.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,038.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$935.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$380.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$444.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,114.96
|
| Rate for Payer: Ohio Health Group HMO |
$950.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$253.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$392.77
|
| Rate for Payer: PHCS Commercial |
$1,216.32
|
| Rate for Payer: United Healthcare All Payer |
$1,114.96
|
|
