|
INFINEON SPLITTER 2*8
|
Facility
|
OP
|
$7,180.00
|
|
|
Service Code
|
HCPCS C1883
|
| Hospital Charge Code |
27000063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.40 |
| Max. Negotiated Rate |
$6,892.80 |
| Rate for Payer: Aetna Commercial |
$5,528.60
|
| Rate for Payer: Anthem Medicaid |
$2,469.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,600.40
|
| Rate for Payer: Cash Price |
$3,590.00
|
| Rate for Payer: Cigna Commercial |
$5,959.40
|
| Rate for Payer: First Health Commercial |
$6,821.00
|
| Rate for Payer: Humana Commercial |
$6,103.00
|
| Rate for Payer: Humana KY Medicaid |
$2,469.20
|
| Rate for Payer: Kentucky WC Medicaid |
$2,494.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,887.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,298.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,154.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,518.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,318.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,385.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$933.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,225.80
|
| Rate for Payer: PHCS Commercial |
$6,892.80
|
| Rate for Payer: United Healthcare All Payer |
$6,318.40
|
|
|
INFINEON TRIAL LEAD KIT 50CM
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
INFINEON TRIAL LEAD KIT 50CM
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
INFINION 16 LEAD KIT 70CM
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
INFINION 16 LEAD KIT 70CM
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
INFINION CX LEAD KIT 50CM
|
Facility
|
OP
|
$20,860.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.80 |
| Max. Negotiated Rate |
$20,025.60 |
| Rate for Payer: Aetna Commercial |
$16,062.20
|
| Rate for Payer: Anthem Medicaid |
$7,173.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,270.80
|
| Rate for Payer: Cash Price |
$10,430.00
|
| Rate for Payer: Cigna Commercial |
$17,313.80
|
| Rate for Payer: First Health Commercial |
$19,817.00
|
| Rate for Payer: Humana Commercial |
$17,731.00
|
| Rate for Payer: Humana KY Medicaid |
$7,173.75
|
| Rate for Payer: Kentucky WC Medicaid |
$7,246.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,105.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,394.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,258.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,317.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,356.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,466.60
|
| Rate for Payer: PHCS Commercial |
$20,025.60
|
| Rate for Payer: United Healthcare All Payer |
$18,356.80
|
|
|
INFINION CX LEAD KIT 50CM
|
Facility
|
IP
|
$20,860.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.80 |
| Max. Negotiated Rate |
$20,025.60 |
| Rate for Payer: Aetna Commercial |
$16,062.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,270.80
|
| Rate for Payer: Cash Price |
$10,430.00
|
| Rate for Payer: Cigna Commercial |
$17,313.80
|
| Rate for Payer: First Health Commercial |
$19,817.00
|
| Rate for Payer: Humana Commercial |
$17,731.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,105.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,394.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,258.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,356.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,466.60
|
| Rate for Payer: PHCS Commercial |
$20,025.60
|
| Rate for Payer: United Healthcare All Payer |
$18,356.80
|
|
|
INFINION CX LEAD KIT 70CM
|
Facility
|
OP
|
$20,860.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.80 |
| Max. Negotiated Rate |
$20,025.60 |
| Rate for Payer: Aetna Commercial |
$16,062.20
|
| Rate for Payer: Anthem Medicaid |
$7,173.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,270.80
|
| Rate for Payer: Cash Price |
$10,430.00
|
| Rate for Payer: Cigna Commercial |
$17,313.80
|
| Rate for Payer: First Health Commercial |
$19,817.00
|
| Rate for Payer: Humana Commercial |
$17,731.00
|
| Rate for Payer: Humana KY Medicaid |
$7,173.75
|
| Rate for Payer: Kentucky WC Medicaid |
$7,246.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,105.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,394.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,258.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,317.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,356.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,466.60
|
| Rate for Payer: PHCS Commercial |
$20,025.60
|
| Rate for Payer: United Healthcare All Payer |
$18,356.80
|
|
|
INFINION CX LEAD KIT 70CM
|
Facility
|
IP
|
$20,860.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.80 |
| Max. Negotiated Rate |
$20,025.60 |
| Rate for Payer: Aetna Commercial |
$16,062.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,270.80
|
| Rate for Payer: Cash Price |
$10,430.00
|
| Rate for Payer: Cigna Commercial |
$17,313.80
|
| Rate for Payer: First Health Commercial |
$19,817.00
|
| Rate for Payer: Humana Commercial |
$17,731.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,105.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,394.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,258.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,356.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,466.60
|
| Rate for Payer: PHCS Commercial |
$20,025.60
|
| Rate for Payer: United Healthcare All Payer |
$18,356.80
|
|
|
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$18,962.79
|
|
|
Service Code
|
MSDRG 727
|
| Min. Negotiated Rate |
$12,867.61 |
| Max. Negotiated Rate |
$18,962.79 |
| Rate for Payer: Anthem Medicaid |
$12,867.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,544.85
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18,962.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,285.55
|
| Rate for Payer: Humana KY Medicaid |
$12,867.61
|
| Rate for Payer: Humana Medicare Advantage |
$13,544.85
|
| Rate for Payer: Kentucky WC Medicaid |
$12,996.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,253.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,124.96
|
|
|
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC
|
Facility
|
IP
|
$9,359.74
|
|
|
Service Code
|
MSDRG 728
|
| Min. Negotiated Rate |
$6,351.25 |
| Max. Negotiated Rate |
$9,359.74 |
| Rate for Payer: Anthem Medicaid |
$6,351.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,685.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,359.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,025.47
|
| Rate for Payer: Humana KY Medicaid |
$6,351.25
|
| Rate for Payer: Humana Medicare Advantage |
$6,685.53
|
| Rate for Payer: Kentucky WC Medicaid |
$6,414.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,022.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,478.28
|
|
|
INFLAMMATORY BOWEL DISEASE WITH CC
|
Facility
|
IP
|
$11,366.00
|
|
|
Service Code
|
MSDRG 386
|
| Min. Negotiated Rate |
$7,712.64 |
| Max. Negotiated Rate |
$11,366.00 |
| Rate for Payer: Anthem Medicaid |
$7,712.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,118.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,366.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,960.07
|
| Rate for Payer: Humana KY Medicaid |
$7,712.64
|
| Rate for Payer: Humana Medicare Advantage |
$8,118.57
|
| Rate for Payer: Kentucky WC Medicaid |
$7,789.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,742.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,866.89
|
|
|
INFLAMMATORY BOWEL DISEASE WITH MCC
|
Facility
|
IP
|
$18,329.89
|
|
|
Service Code
|
MSDRG 385
|
| Min. Negotiated Rate |
$12,438.14 |
| Max. Negotiated Rate |
$18,329.89 |
| Rate for Payer: Anthem Medicaid |
$12,438.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,092.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18,329.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$17,675.25
|
| Rate for Payer: Humana KY Medicaid |
$12,438.14
|
| Rate for Payer: Humana Medicare Advantage |
$13,092.78
|
| Rate for Payer: Kentucky WC Medicaid |
$12,562.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,711.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,686.90
|
|
|
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$8,002.75
|
|
|
Service Code
|
MSDRG 387
|
| Min. Negotiated Rate |
$5,430.44 |
| Max. Negotiated Rate |
$8,002.75 |
| Rate for Payer: Anthem Medicaid |
$5,430.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,716.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,002.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,716.94
|
| Rate for Payer: Humana KY Medicaid |
$5,430.44
|
| Rate for Payer: Humana Medicare Advantage |
$5,716.25
|
| Rate for Payer: Kentucky WC Medicaid |
$5,484.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,859.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,539.05
|
|
|
INFLECTRA 100MG VIAL
|
Facility
|
IP
|
$1,888.28
|
|
|
Service Code
|
HCPCS Q5103
|
| Hospital Charge Code |
25002726
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.48 |
| Max. Negotiated Rate |
$1,812.75 |
| Rate for Payer: Aetna Commercial |
$1,453.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,472.86
|
| Rate for Payer: Cash Price |
$944.14
|
| Rate for Payer: Cigna Commercial |
$1,567.27
|
| Rate for Payer: First Health Commercial |
$1,793.87
|
| Rate for Payer: Humana Commercial |
$1,605.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,393.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,661.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$377.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$245.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.37
|
| Rate for Payer: PHCS Commercial |
$1,812.75
|
| Rate for Payer: United Healthcare All Payer |
$1,661.69
|
|
|
INFLECTRA 100MG VIAL
|
Facility
|
OP
|
$1,888.28
|
|
|
Service Code
|
HCPCS Q5103
|
| Hospital Charge Code |
25002726
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$1,812.75 |
| Rate for Payer: Aetna Commercial |
$1,453.98
|
| Rate for Payer: Anthem Medicaid |
$649.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,472.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.30
|
| Rate for Payer: Cash Price |
$944.14
|
| Rate for Payer: Cash Price |
$944.14
|
| Rate for Payer: Cigna Commercial |
$1,567.27
|
| Rate for Payer: First Health Commercial |
$1,793.87
|
| Rate for Payer: Humana Commercial |
$1,605.04
|
| Rate for Payer: Humana KY Medicaid |
$649.38
|
| Rate for Payer: Humana Medicare Advantage |
$14.29
|
| Rate for Payer: Kentucky WC Medicaid |
$655.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,393.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$662.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,661.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$377.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$245.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.37
|
| Rate for Payer: PHCS Commercial |
$1,812.75
|
| Rate for Payer: United Healthcare All Payer |
$1,661.69
|
|
|
INFLIXIMAB 10MG (100MG)
|
Facility
|
OP
|
$6,364.62
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
25002160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.16 |
| Max. Negotiated Rate |
$6,110.04 |
| Rate for Payer: Aetna Commercial |
$4,900.76
|
| Rate for Payer: Anthem Medicaid |
$2,188.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,964.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$43.42
|
| Rate for Payer: Cash Price |
$3,182.31
|
| Rate for Payer: Cash Price |
$3,182.31
|
| Rate for Payer: Cigna Commercial |
$5,282.63
|
| Rate for Payer: First Health Commercial |
$6,046.39
|
| Rate for Payer: Humana Commercial |
$5,409.93
|
| Rate for Payer: Humana KY Medicaid |
$2,188.79
|
| Rate for Payer: Humana Medicare Advantage |
$32.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,211.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,218.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,697.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,232.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,600.87
|
| Rate for Payer: Ohio Health Group HMO |
$4,773.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,272.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$827.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,973.03
|
| Rate for Payer: PHCS Commercial |
$6,110.04
|
| Rate for Payer: United Healthcare All Payer |
$5,600.87
|
|
|
INFLIXIMAB 10MG (100MG)
|
Facility
|
IP
|
$6,364.62
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
25002160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$827.40 |
| Max. Negotiated Rate |
$6,110.04 |
| Rate for Payer: Aetna Commercial |
$4,900.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,964.40
|
| Rate for Payer: Cash Price |
$3,182.31
|
| Rate for Payer: Cigna Commercial |
$5,282.63
|
| Rate for Payer: First Health Commercial |
$6,046.39
|
| Rate for Payer: Humana Commercial |
$5,409.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,218.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,697.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,909.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,600.87
|
| Rate for Payer: Ohio Health Group HMO |
$4,773.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,272.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$827.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,973.03
|
| Rate for Payer: PHCS Commercial |
$6,110.04
|
| Rate for Payer: United Healthcare All Payer |
$5,600.87
|
|
|
inFLIXimab-AXXQ 100mg VIAL
|
Facility
|
OP
|
$2,725.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
25004020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.56 |
| Max. Negotiated Rate |
$2,616.00 |
| Rate for Payer: Anthem Medicaid |
$937.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,125.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.50
|
| Rate for Payer: Cash Price |
$1,362.50
|
| Rate for Payer: Cash Price |
$1,362.50
|
| Rate for Payer: Cigna Commercial |
$2,261.75
|
| Rate for Payer: First Health Commercial |
$2,588.75
|
| Rate for Payer: Humana Commercial |
$2,316.25
|
| Rate for Payer: Humana KY Medicaid |
$937.13
|
| Rate for Payer: Humana Medicare Advantage |
$25.56
|
| Rate for Payer: Kentucky WC Medicaid |
$946.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,234.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$955.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,043.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$545.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$354.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$844.75
|
| Rate for Payer: PHCS Commercial |
$2,616.00
|
| Rate for Payer: United Healthcare All Payer |
$2,398.00
|
| Rate for Payer: Aetna Commercial |
$2,098.25
|
|
|
inFLIXimab-AXXQ 100mg VIAL
|
Facility
|
IP
|
$2,725.00
|
|
|
Service Code
|
HCPCS Q5121
|
| Hospital Charge Code |
25004020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$354.25 |
| Max. Negotiated Rate |
$2,616.00 |
| Rate for Payer: Aetna Commercial |
$2,098.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,125.50
|
| Rate for Payer: Cash Price |
$1,362.50
|
| Rate for Payer: Cigna Commercial |
$2,261.75
|
| Rate for Payer: First Health Commercial |
$2,588.75
|
| Rate for Payer: Humana Commercial |
$2,316.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,234.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$817.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,043.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$545.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$354.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$844.75
|
| Rate for Payer: PHCS Commercial |
$2,616.00
|
| Rate for Payer: United Healthcare All Payer |
$2,398.00
|
|
|
INFLUENZA A&B PCR
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
30001372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.89 |
| Max. Negotiated Rate |
$242.88 |
| Rate for Payer: Aetna Commercial |
$194.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.16
|
| Rate for Payer: Cash Price |
$126.50
|
| Rate for Payer: Cigna Commercial |
$209.99
|
| Rate for Payer: First Health Commercial |
$240.35
|
| Rate for Payer: Humana Commercial |
$215.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$207.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$222.64
|
| Rate for Payer: Ohio Health Group HMO |
$189.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.43
|
| Rate for Payer: PHCS Commercial |
$242.88
|
| Rate for Payer: United Healthcare All Payer |
$222.64
|
|
|
INFLUENZA A&B PCR
|
Professional
|
Both
|
$253.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
30001372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.48 |
| Max. Negotiated Rate |
$253.00 |
| Rate for Payer: Aetna Commercial |
$191.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$253.00
|
| Rate for Payer: Cash Price |
$126.50
|
| Rate for Payer: Cash Price |
$126.50
|
| Rate for Payer: Cigna Commercial |
$84.41
|
| Rate for Payer: Healthspan PPO |
$89.81
|
| Rate for Payer: Multiplan PHCS |
$151.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.10
|
| Rate for Payer: UHCCP Medicaid |
$88.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.48
|
|
|
INFLUENZA A&B PCR
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
30001372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.89 |
| Max. Negotiated Rate |
$242.88 |
| Rate for Payer: Aetna Commercial |
$194.81
|
| Rate for Payer: Anthem Medicaid |
$95.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$134.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.80
|
| Rate for Payer: Cash Price |
$126.50
|
| Rate for Payer: Cash Price |
$126.50
|
| Rate for Payer: Cigna Commercial |
$209.99
|
| Rate for Payer: First Health Commercial |
$240.35
|
| Rate for Payer: Humana Commercial |
$215.05
|
| Rate for Payer: Humana KY Medicaid |
$95.80
|
| Rate for Payer: Humana Medicare Advantage |
$95.80
|
| Rate for Payer: Kentucky WC Medicaid |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$207.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$222.64
|
| Rate for Payer: Ohio Health Group HMO |
$189.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.43
|
| Rate for Payer: PHCS Commercial |
$242.88
|
| Rate for Payer: United Healthcare All Payer |
$222.64
|
|
|
INFLUENZA A&B RSV PNL
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 87631
|
| Hospital Charge Code |
30001387
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$57.46 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.93
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.02
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
INFLUENZA A&B RSV PNL
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 87631
|
| Hospital Charge Code |
30001387
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$57.46 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$142.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$142.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$199.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$142.63
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$142.63
|
| Rate for Payer: Humana Medicare Advantage |
$142.63
|
| Rate for Payer: Kentucky WC Medicaid |
$144.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.02
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
