|
IM/SQ INJECTION(T
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
260T0008
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.03
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
IMT 5FR
|
Facility
|
IP
|
$175.16
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.55 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Aetna Commercial |
$134.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$136.62
|
| Rate for Payer: Cash Price |
$87.58
|
| Rate for Payer: Cigna Commercial |
$145.38
|
| Rate for Payer: First Health Commercial |
$166.40
|
| Rate for Payer: Humana Commercial |
$148.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$143.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.14
|
| Rate for Payer: Ohio Health Group HMO |
$131.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.86
|
| Rate for Payer: PHCS Commercial |
$168.15
|
| Rate for Payer: United Healthcare All Payer |
$154.14
|
|
|
IMT 5FR
|
Facility
|
OP
|
$175.16
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.55 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Aetna Commercial |
$134.87
|
| Rate for Payer: Anthem Medicaid |
$60.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$136.62
|
| Rate for Payer: Cash Price |
$87.58
|
| Rate for Payer: Cigna Commercial |
$145.38
|
| Rate for Payer: First Health Commercial |
$166.40
|
| Rate for Payer: Humana Commercial |
$148.89
|
| Rate for Payer: Humana KY Medicaid |
$60.24
|
| Rate for Payer: Kentucky WC Medicaid |
$60.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$143.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$61.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.14
|
| Rate for Payer: Ohio Health Group HMO |
$131.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.86
|
| Rate for Payer: PHCS Commercial |
$168.15
|
| Rate for Payer: United Healthcare All Payer |
$154.14
|
|
|
IMT CATH 5FR
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
IMT CATH 5FR
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
IMURAN (AZATHIOPRINE 50MG/1TAB
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
25002491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| 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 |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
IMURAN (AZATHIOPRINE 50MG/1TAB
|
Facility
|
OP
|
$4.88
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
25002491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| 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 |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| 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 |
$890.10 |
| 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 |
$2,373.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,581.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,047.23
|
| 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 |
$890.10 |
| 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 |
$2,373.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,581.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,047.23
|
| Rate for Payer: PHCS Commercial |
$2,848.32
|
| Rate for Payer: United Healthcare All Payer |
$2,610.96
|
|
|
IN111 IBRITUMOMAB, DX
|
Facility
|
IP
|
$3,804.00
|
|
|
Service Code
|
HCPCS A9542
|
| Hospital Charge Code |
34000057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,141.20 |
| 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 |
$3,043.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,309.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,624.76
|
| Rate for Payer: PHCS Commercial |
$3,651.84
|
| Rate for Payer: United Healthcare All Payer |
$3,347.52
|
|
|
IN111 IBRITUMOMAB, DX
|
Facility
|
OP
|
$3,804.00
|
|
|
Service Code
|
HCPCS A9542
|
| Hospital Charge Code |
34000057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$798.02 |
| 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 Medicare Advantage/PPO |
$798.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,967.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,117.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,077.33
|
| Rate for Payer: Cash Price |
$1,902.00
|
| 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: Humana Medicare Advantage |
$798.02
|
| 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 |
$957.62
|
| 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 |
$3,043.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,309.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,624.76
|
| 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 |
$495.30 |
| 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 |
$1,320.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,436.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,139.19
|
| 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 |
$567.78 |
| 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 Medicare Advantage/PPO |
$772.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,081.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,043.06
|
| Rate for Payer: Cash Price |
$825.50
|
| 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: Humana Medicare Advantage |
$772.64
|
| 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 |
$927.17
|
| 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 |
$1,320.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,436.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,139.19
|
| Rate for Payer: PHCS Commercial |
$1,584.96
|
| Rate for Payer: United Healthcare All Payer |
$1,452.88
|
|
|
IN 111 OXYQUINOLINE PER 0.5MCI
|
Professional
|
Both
|
$1,651.00
|
|
| Hospital Charge Code |
34000059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$577.85 |
| Max. Negotiated Rate |
$1,155.70 |
| Rate for Payer: Cash Price |
$825.50
|
| Rate for Payer: Multiplan PHCS |
$990.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,155.70
|
| Rate for Payer: UHCCP Medicaid |
$577.85
|
|
|
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 |
$495.30 |
| 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 |
$1,320.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,436.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,139.19
|
| 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 |
$567.78 |
| 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 Medicare Advantage/PPO |
$772.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,081.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,043.06
|
| Rate for Payer: Cash Price |
$825.50
|
| 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: Humana Medicare Advantage |
$772.64
|
| 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 |
$927.17
|
| 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 |
$1,320.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,436.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,139.19
|
| 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 |
$380.10 |
| 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 |
$1,013.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,102.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$874.23
|
| 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 |
$435.72 |
| Max. Negotiated Rate |
$1,216.32 |
| Rate for Payer: Aetna Commercial |
$975.59
|
| Rate for Payer: Anthem Medicaid |
$435.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$715.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$988.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,001.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$965.64
|
| Rate for Payer: Cash Price |
$633.50
|
| 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: Humana Medicare Advantage |
$715.29
|
| 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 |
$858.35
|
| 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 |
$1,013.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,102.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$874.23
|
| 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(T
|
Facility
|
IP
|
$1,267.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
340T0060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$380.10 |
| 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 |
$1,013.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,102.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$874.23
|
| 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(T
|
Facility
|
OP
|
$1,267.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
340T0060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$435.72 |
| Max. Negotiated Rate |
$1,216.32 |
| Rate for Payer: Aetna Commercial |
$975.59
|
| Rate for Payer: Anthem Medicaid |
$435.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$715.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$988.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,001.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$965.64
|
| Rate for Payer: Cash Price |
$633.50
|
| 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: Humana Medicare Advantage |
$715.29
|
| 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 |
$858.35
|
| 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 |
$1,013.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,102.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$874.23
|
| Rate for Payer: PHCS Commercial |
$1,216.32
|
| Rate for Payer: United Healthcare All Payer |
$1,114.96
|
|
|
INCAL BX SKN EA SEP/ADDL
|
Professional
|
Both
|
$997.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
76100036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$598.20 |
| Rate for Payer: Ambetter Exchange |
$28.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.10
|
| Rate for Payer: Anthem Medicaid |
$55.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.33
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cigna Commercial |
$114.39
|
| Rate for Payer: Humana Medicaid |
$55.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$28.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.16
|
| Rate for Payer: Molina Healthcare Passport |
$55.06
|
| Rate for Payer: Multiplan PHCS |
$598.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.19
|
| Rate for Payer: UHCCP Medicaid |
$25.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.61
|
|
|
INCAL BX SKN EA SEP/ADDL
|
Facility
|
OP
|
$997.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
76100036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.10 |
| Max. Negotiated Rate |
$957.12 |
| Rate for Payer: Aetna Commercial |
$767.69
|
| Rate for Payer: Anthem Medicaid |
$342.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$777.66
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cigna Commercial |
$827.51
|
| Rate for Payer: First Health Commercial |
$947.15
|
| Rate for Payer: Humana Commercial |
$847.45
|
| Rate for Payer: Humana KY Medicaid |
$342.87
|
| Rate for Payer: Kentucky WC Medicaid |
$346.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$817.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$735.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$299.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$349.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$877.36
|
| Rate for Payer: Ohio Health Group HMO |
$747.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$797.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$867.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$687.93
|
| Rate for Payer: PHCS Commercial |
$957.12
|
| Rate for Payer: United Healthcare All Payer |
$877.36
|
|
|
INCAL BX SKN EA SEP/ADDL
|
Facility
|
IP
|
$997.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
76100036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.10 |
| Max. Negotiated Rate |
$957.12 |
| Rate for Payer: Aetna Commercial |
$767.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$777.66
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cigna Commercial |
$827.51
|
| Rate for Payer: First Health Commercial |
$947.15
|
| Rate for Payer: Humana Commercial |
$847.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$817.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$735.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$299.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$877.36
|
| Rate for Payer: Ohio Health Group HMO |
$747.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$797.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$867.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$687.93
|
| Rate for Payer: PHCS Commercial |
$957.12
|
| Rate for Payer: United Healthcare All Payer |
$877.36
|
|
|
INCAL BX SKN EA SEP/ADDL(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
761P0036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Ambetter Exchange |
$28.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.10
|
| Rate for Payer: Anthem Medicaid |
$55.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.33
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$114.39
|
| Rate for Payer: Humana Medicaid |
$55.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$28.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.16
|
| Rate for Payer: Molina Healthcare Passport |
$55.06
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.19
|
| Rate for Payer: UHCCP Medicaid |
$25.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.61
|
|
|
INCAL BX SKN EA SEP/ADDL(T
|
Facility
|
OP
|
$762.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
761T0036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$228.60 |
| Max. Negotiated Rate |
$731.52 |
| Rate for Payer: Aetna Commercial |
$586.74
|
| Rate for Payer: Anthem Medicaid |
$262.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$594.36
|
| Rate for Payer: Cash Price |
$381.00
|
| Rate for Payer: Cigna Commercial |
$632.46
|
| Rate for Payer: First Health Commercial |
$723.90
|
| Rate for Payer: Humana Commercial |
$647.70
|
| Rate for Payer: Humana KY Medicaid |
$262.05
|
| Rate for Payer: Kentucky WC Medicaid |
$264.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$624.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$562.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$670.56
|
| Rate for Payer: Ohio Health Group HMO |
$571.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$609.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$662.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$525.78
|
| Rate for Payer: PHCS Commercial |
$731.52
|
| Rate for Payer: United Healthcare All Payer |
$670.56
|
|
