|
IMFINZI 10MG (120MG VIAL)
|
Facility
|
IP
|
$5,507.28
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
25002607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,652.18 |
| Max. Negotiated Rate |
$5,286.99 |
| Rate for Payer: Aetna Commercial |
$4,240.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,295.68
|
| Rate for Payer: Cash Price |
$2,753.64
|
| Rate for Payer: Cigna Commercial |
$4,571.04
|
| Rate for Payer: First Health Commercial |
$5,231.92
|
| Rate for Payer: Humana Commercial |
$4,681.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,515.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,064.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,652.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,846.41
|
| Rate for Payer: Ohio Health Group HMO |
$4,130.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,405.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,791.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,800.02
|
| Rate for Payer: PHCS Commercial |
$5,286.99
|
| Rate for Payer: United Healthcare All Payer |
$4,846.41
|
|
|
IMFINZI 10MG (120MG VIAL)
|
Facility
|
OP
|
$5,507.28
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
25002607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.25 |
| Max. Negotiated Rate |
$5,286.99 |
| Rate for Payer: Aetna Commercial |
$4,240.61
|
| Rate for Payer: Anthem Medicaid |
$1,893.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,295.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$115.09
|
| Rate for Payer: Cash Price |
$2,753.64
|
| Rate for Payer: Cash Price |
$2,753.64
|
| Rate for Payer: Cigna Commercial |
$4,571.04
|
| Rate for Payer: First Health Commercial |
$5,231.92
|
| Rate for Payer: Humana Commercial |
$4,681.19
|
| Rate for Payer: Humana KY Medicaid |
$1,893.95
|
| Rate for Payer: Humana Medicare Advantage |
$85.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,913.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,515.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,064.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,931.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,846.41
|
| Rate for Payer: Ohio Health Group HMO |
$4,130.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,405.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,791.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,800.02
|
| Rate for Payer: PHCS Commercial |
$5,286.99
|
| Rate for Payer: United Healthcare All Payer |
$4,846.41
|
|
|
IMFINZI 10MG (500MG VL)
|
Facility
|
IP
|
$22,946.95
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
25003911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,884.09 |
| Max. Negotiated Rate |
$22,029.07 |
| Rate for Payer: Aetna Commercial |
$17,669.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,898.62
|
| Rate for Payer: Cash Price |
$11,473.48
|
| Rate for Payer: Cigna Commercial |
$19,045.97
|
| Rate for Payer: First Health Commercial |
$21,799.60
|
| Rate for Payer: Humana Commercial |
$19,504.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,816.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,934.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,884.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,193.32
|
| Rate for Payer: Ohio Health Group HMO |
$17,210.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,357.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,963.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,833.40
|
| Rate for Payer: PHCS Commercial |
$22,029.07
|
| Rate for Payer: United Healthcare All Payer |
$20,193.32
|
|
|
IMFINZI 10MG (500MG VL)
|
Facility
|
OP
|
$22,946.95
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
25003911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.25 |
| Max. Negotiated Rate |
$22,029.07 |
| Rate for Payer: Aetna Commercial |
$17,669.15
|
| Rate for Payer: Anthem Medicaid |
$7,891.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,898.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$115.09
|
| Rate for Payer: Cash Price |
$11,473.48
|
| Rate for Payer: Cash Price |
$11,473.48
|
| Rate for Payer: Cigna Commercial |
$19,045.97
|
| Rate for Payer: First Health Commercial |
$21,799.60
|
| Rate for Payer: Humana Commercial |
$19,504.91
|
| Rate for Payer: Humana KY Medicaid |
$7,891.46
|
| Rate for Payer: Humana Medicare Advantage |
$85.25
|
| Rate for Payer: Kentucky WC Medicaid |
$7,971.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,816.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,934.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,049.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,193.32
|
| Rate for Payer: Ohio Health Group HMO |
$17,210.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,357.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,963.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,833.40
|
| Rate for Payer: PHCS Commercial |
$22,029.07
|
| Rate for Payer: United Healthcare All Payer |
$20,193.32
|
|
|
IMG RTA DETC/MNTR DS POC ALY
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
51000364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$202.56 |
| Rate for Payer: Aetna Commercial |
$162.47
|
| Rate for Payer: Anthem Medicaid |
$72.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$164.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$175.13
|
| Rate for Payer: First Health Commercial |
$200.45
|
| Rate for Payer: Humana Commercial |
$179.35
|
| Rate for Payer: Humana KY Medicaid |
$72.56
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$73.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$74.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$185.68
|
| Rate for Payer: Ohio Health Group HMO |
$158.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.59
|
| Rate for Payer: PHCS Commercial |
$202.56
|
| Rate for Payer: United Healthcare All Payer |
$185.68
|
|
|
IMG RTA DETC/MNTR DS POC ALY
|
Professional
|
Both
|
$211.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
51000364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.82 |
| Max. Negotiated Rate |
$126.60 |
| Rate for Payer: Ambetter Exchange |
$39.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.78
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.82
|
| Rate for Payer: Multiplan PHCS |
$126.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.77
|
| Rate for Payer: UHCCP Medicaid |
$73.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.82
|
|
|
IMG RTA DETC/MNTR DS POC ALY
|
Professional
|
Both
|
$211.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
92000015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.82 |
| Max. Negotiated Rate |
$126.60 |
| Rate for Payer: Ambetter Exchange |
$39.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.78
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.82
|
| Rate for Payer: Multiplan PHCS |
$126.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.77
|
| Rate for Payer: UHCCP Medicaid |
$73.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.82
|
|
|
IMG RTA DETC/MNTR DS POC ALY
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
51000364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.30 |
| Max. Negotiated Rate |
$202.56 |
| Rate for Payer: Aetna Commercial |
$162.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$164.58
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$175.13
|
| Rate for Payer: First Health Commercial |
$200.45
|
| Rate for Payer: Humana Commercial |
$179.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$185.68
|
| Rate for Payer: Ohio Health Group HMO |
$158.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.59
|
| Rate for Payer: PHCS Commercial |
$202.56
|
| Rate for Payer: United Healthcare All Payer |
$185.68
|
|
|
IMG RTA DETC/MNTR DS POC ALY
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
92000015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$63.30 |
| Max. Negotiated Rate |
$202.56 |
| Rate for Payer: Aetna Commercial |
$162.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$164.58
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$175.13
|
| Rate for Payer: First Health Commercial |
$200.45
|
| Rate for Payer: Humana Commercial |
$179.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$185.68
|
| Rate for Payer: Ohio Health Group HMO |
$158.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.59
|
| Rate for Payer: PHCS Commercial |
$202.56
|
| Rate for Payer: United Healthcare All Payer |
$185.68
|
|
|
IMG RTA DETC/MNTR DS POC ALY
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
92000015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$202.56 |
| Rate for Payer: Aetna Commercial |
$162.47
|
| Rate for Payer: Anthem Medicaid |
$72.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$164.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$175.13
|
| Rate for Payer: First Health Commercial |
$200.45
|
| Rate for Payer: Humana Commercial |
$179.35
|
| Rate for Payer: Humana KY Medicaid |
$72.56
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$73.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$74.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$185.68
|
| Rate for Payer: Ohio Health Group HMO |
$158.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.59
|
| Rate for Payer: PHCS Commercial |
$202.56
|
| Rate for Payer: United Healthcare All Payer |
$185.68
|
|
|
IMG RTA DETC/MNTR DS POC ALY(P
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
920P0015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Ambetter Exchange |
$39.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.78
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.82
|
| Rate for Payer: Multiplan PHCS |
$52.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.77
|
| Rate for Payer: UHCCP Medicaid |
$30.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.82
|
|
|
IMG RTA DETC/MNTR DS POC ALY(P
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
510P0364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Ambetter Exchange |
$39.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.78
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.82
|
| Rate for Payer: Multiplan PHCS |
$52.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.77
|
| Rate for Payer: UHCCP Medicaid |
$30.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.82
|
|
|
IMG RTA DETC/MNTR DS POC ALY(T
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
510T0364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$42.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$42.30
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$42.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
IMG RTA DETC/MNTR DS POC ALY(T
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
920T0015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$42.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$42.30
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$42.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
IMG RTA DETC/MNTR DS POC ALY(T
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
920T0015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
IMG RTA DETC/MNTR DS POC ALY(T
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 92229
|
| Hospital Charge Code |
510T0364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
IM GUIDE 8FR
|
Facility
|
OP
|
$835.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.50 |
| Max. Negotiated Rate |
$801.60 |
| Rate for Payer: Aetna Commercial |
$642.95
|
| Rate for Payer: Anthem Medicaid |
$287.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$651.30
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cigna Commercial |
$693.05
|
| Rate for Payer: First Health Commercial |
$793.25
|
| Rate for Payer: Humana Commercial |
$709.75
|
| Rate for Payer: Humana KY Medicaid |
$287.16
|
| Rate for Payer: Kentucky WC Medicaid |
$290.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$684.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$292.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$734.80
|
| Rate for Payer: Ohio Health Group HMO |
$626.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.15
|
| Rate for Payer: PHCS Commercial |
$801.60
|
| Rate for Payer: United Healthcare All Payer |
$734.80
|
|
|
IM GUIDE 8FR
|
Facility
|
IP
|
$835.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.50 |
| Max. Negotiated Rate |
$801.60 |
| Rate for Payer: Aetna Commercial |
$642.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$651.30
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cigna Commercial |
$693.05
|
| Rate for Payer: First Health Commercial |
$793.25
|
| Rate for Payer: Humana Commercial |
$709.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$684.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$734.80
|
| Rate for Payer: Ohio Health Group HMO |
$626.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.15
|
| Rate for Payer: PHCS Commercial |
$801.60
|
| Rate for Payer: United Healthcare All Payer |
$734.80
|
|
|
IM INJECTION & SQ
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
94000003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.20
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
IM INJECTION & SQ
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
94000003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna Commercial |
$31.94
|
| Rate for Payer: Ambetter Exchange |
$13.20
|
| Rate for Payer: Anthem Medicaid |
$18.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$13.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$13.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.84
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: Healthspan PPO |
$29.93
|
| Rate for Payer: Humana Medicaid |
$18.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$13.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.46
|
| Rate for Payer: Molina Healthcare Passport |
$18.10
|
| Rate for Payer: Multiplan PHCS |
$54.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.16
|
| Rate for Payer: UHCCP Medicaid |
$31.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$13.20
|
|
|
IM INJECTION & SQ
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
94000003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$30.95 |
| Max. Negotiated Rate |
$92.06 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem Medicaid |
$30.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.78
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Humana KY Medicaid |
$30.95
|
| Rate for Payer: Humana Medicare Advantage |
$65.76
|
| Rate for Payer: Kentucky WC Medicaid |
$31.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
IM INJECTION & SQ (T
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
940T0003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.20
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
IM INJECTION & SQ (T
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
940T0003
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$30.95 |
| Max. Negotiated Rate |
$92.06 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem Medicaid |
$30.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.78
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Humana KY Medicaid |
$30.95
|
| Rate for Payer: Humana Medicare Advantage |
$65.76
|
| Rate for Payer: Kentucky WC Medicaid |
$31.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
IMITREX (SUMATRIPTAN 25MG/1TAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 65862014636
|
| Hospital Charge Code |
25000772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
IMITREX (SUMATRIPTAN 25MG/1TAB
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 65862014636
|
| Hospital Charge Code |
25000772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
