|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Professional
|
Both
|
$6,993.00
|
|
| Hospital Charge Code |
34000070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,447.55 |
| Max. Negotiated Rate |
$4,895.10 |
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Multiplan PHCS |
$4,195.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,895.10
|
| Rate for Payer: UHCCP Medicaid |
$2,447.55
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
IP
|
$6,993.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
34000070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,097.90 |
| Max. Negotiated Rate |
$6,713.28 |
| Rate for Payer: Aetna Commercial |
$5,384.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,454.54
|
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Cigna Commercial |
$5,804.19
|
| Rate for Payer: First Health Commercial |
$6,643.35
|
| Rate for Payer: Humana Commercial |
$5,944.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,734.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,160.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,097.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,153.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,244.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,594.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,083.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,825.17
|
| Rate for Payer: PHCS Commercial |
$6,713.28
|
| Rate for Payer: United Healthcare All Payer |
$6,153.84
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
IP
|
$6,993.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
340T0070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,097.90 |
| Max. Negotiated Rate |
$6,713.28 |
| Rate for Payer: Aetna Commercial |
$5,384.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,454.54
|
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Cigna Commercial |
$5,804.19
|
| Rate for Payer: First Health Commercial |
$6,643.35
|
| Rate for Payer: Humana Commercial |
$5,944.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,734.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,160.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,097.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,153.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,244.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,594.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,083.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,825.17
|
| Rate for Payer: PHCS Commercial |
$6,713.28
|
| Rate for Payer: United Healthcare All Payer |
$6,153.84
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
OP
|
$6,993.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
340T0070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,031.39 |
| Max. Negotiated Rate |
$6,713.28 |
| Rate for Payer: Aetna Commercial |
$5,384.61
|
| Rate for Payer: Anthem Medicaid |
$2,404.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,031.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,454.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,443.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,392.38
|
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Cigna Commercial |
$5,804.19
|
| Rate for Payer: First Health Commercial |
$6,643.35
|
| Rate for Payer: Humana Commercial |
$5,944.05
|
| Rate for Payer: Humana KY Medicaid |
$2,404.89
|
| Rate for Payer: Humana Medicare Advantage |
$1,031.39
|
| Rate for Payer: Kentucky WC Medicaid |
$2,429.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,734.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,160.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,453.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,153.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,244.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,594.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,083.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,825.17
|
| Rate for Payer: PHCS Commercial |
$6,713.28
|
| Rate for Payer: United Healthcare All Payer |
$6,153.84
|
|
|
INDIUM WBC LABELING
|
Facility
|
OP
|
$828.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
34000043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$284.75 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$637.56
|
| Rate for Payer: Anthem Medicaid |
$284.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$645.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: First Health Commercial |
$786.60
|
| Rate for Payer: Humana Commercial |
$703.80
|
| Rate for Payer: Humana KY Medicaid |
$284.75
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$287.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$678.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$611.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$290.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$728.64
|
| Rate for Payer: Ohio Health Group HMO |
$621.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$662.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$571.32
|
| Rate for Payer: PHCS Commercial |
$794.88
|
| Rate for Payer: United Healthcare All Payer |
$728.64
|
|
|
INDIUM WBC LABELING
|
Facility
|
IP
|
$828.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
34000043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$248.40 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$637.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$645.84
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: First Health Commercial |
$786.60
|
| Rate for Payer: Humana Commercial |
$703.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$678.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$611.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$248.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$728.64
|
| Rate for Payer: Ohio Health Group HMO |
$621.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$662.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$571.32
|
| Rate for Payer: PHCS Commercial |
$794.88
|
| Rate for Payer: United Healthcare All Payer |
$728.64
|
|
|
INDIUM WBC LABELING
|
Professional
|
Both
|
$828.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
34000043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$579.60 |
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$496.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$579.60
|
| Rate for Payer: UHCCP Medicaid |
$289.80
|
|
|
INDIUM WBC LABELING(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
340P0043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
INDIUM WBC LABELING(T
|
Facility
|
OP
|
$678.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
340T0043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$233.16 |
| Max. Negotiated Rate |
$650.88 |
| Rate for Payer: Aetna Commercial |
$522.06
|
| Rate for Payer: Anthem Medicaid |
$233.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$528.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna Commercial |
$562.74
|
| Rate for Payer: First Health Commercial |
$644.10
|
| Rate for Payer: Humana Commercial |
$576.30
|
| Rate for Payer: Humana KY Medicaid |
$233.16
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$235.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$555.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$500.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$237.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$596.64
|
| Rate for Payer: Ohio Health Group HMO |
$508.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$542.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$589.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$467.82
|
| Rate for Payer: PHCS Commercial |
$650.88
|
| Rate for Payer: United Healthcare All Payer |
$596.64
|
|
|
INDIUM WBC LABELING(T
|
Facility
|
IP
|
$678.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
340T0043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$203.40 |
| Max. Negotiated Rate |
$650.88 |
| Rate for Payer: Aetna Commercial |
$522.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$528.84
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna Commercial |
$562.74
|
| Rate for Payer: First Health Commercial |
$644.10
|
| Rate for Payer: Humana Commercial |
$576.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$555.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$500.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$203.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$596.64
|
| Rate for Payer: Ohio Health Group HMO |
$508.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$542.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$589.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$467.82
|
| Rate for Payer: PHCS Commercial |
$650.88
|
| Rate for Payer: United Healthcare All Payer |
$596.64
|
|
|
INDIVIDUAL EXERCISE EA 15 MIN
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
41000098
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$43.80 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.74
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
INDIVIDUAL EXERCISE EA 15 MIN
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
41000098
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$43.80 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Humana KY Medicaid |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.74
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
INDOCIN 50 MG SUPP
|
Facility
|
IP
|
$531.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003123
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$159.57 |
| Max. Negotiated Rate |
$510.63 |
| Rate for Payer: Aetna Commercial |
$409.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.89
|
| Rate for Payer: Cash Price |
$265.96
|
| Rate for Payer: Cigna Commercial |
$441.49
|
| Rate for Payer: First Health Commercial |
$505.31
|
| Rate for Payer: Humana Commercial |
$452.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$436.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$392.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$468.08
|
| Rate for Payer: Ohio Health Group HMO |
$398.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$425.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$462.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$367.02
|
| Rate for Payer: PHCS Commercial |
$510.63
|
| Rate for Payer: United Healthcare All Payer |
$468.08
|
|
|
INDOCIN 50 MG SUPP
|
Facility
|
OP
|
$531.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003123
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$159.57 |
| Max. Negotiated Rate |
$510.63 |
| Rate for Payer: Aetna Commercial |
$409.57
|
| Rate for Payer: Anthem Medicaid |
$182.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.89
|
| Rate for Payer: Cash Price |
$265.96
|
| Rate for Payer: Cigna Commercial |
$441.49
|
| Rate for Payer: First Health Commercial |
$505.31
|
| Rate for Payer: Humana Commercial |
$452.12
|
| Rate for Payer: Humana KY Medicaid |
$182.92
|
| Rate for Payer: Kentucky WC Medicaid |
$184.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$436.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$392.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$468.08
|
| Rate for Payer: Ohio Health Group HMO |
$398.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$425.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$462.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$367.02
|
| Rate for Payer: PHCS Commercial |
$510.63
|
| Rate for Payer: United Healthcare All Payer |
$468.08
|
|
|
INDOCIN (INDOMETHACI 25MG/1CAP
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
25000779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
INDOCIN (INDOMETHACI 25MG/1CAP
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
25000779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
INDOCYANINE GREEN 25MG VIAL
|
Facility
|
OP
|
$563.83
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
25003124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$169.15 |
| Max. Negotiated Rate |
$541.28 |
| Rate for Payer: Aetna Commercial |
$434.15
|
| Rate for Payer: Anthem Medicaid |
$193.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.79
|
| Rate for Payer: Cash Price |
$281.92
|
| Rate for Payer: Cigna Commercial |
$467.98
|
| Rate for Payer: First Health Commercial |
$535.64
|
| Rate for Payer: Humana Commercial |
$479.26
|
| Rate for Payer: Humana KY Medicaid |
$193.90
|
| Rate for Payer: Kentucky WC Medicaid |
$195.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$462.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$197.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$496.17
|
| Rate for Payer: Ohio Health Group HMO |
$422.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$451.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.04
|
| Rate for Payer: PHCS Commercial |
$541.28
|
| Rate for Payer: United Healthcare All Payer |
$496.17
|
|
|
INDOCYANINE GREEN 25MG VIAL
|
Facility
|
IP
|
$563.83
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
25003124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$169.15 |
| Max. Negotiated Rate |
$541.28 |
| Rate for Payer: Aetna Commercial |
$434.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.79
|
| Rate for Payer: Cash Price |
$281.92
|
| Rate for Payer: Cigna Commercial |
$467.98
|
| Rate for Payer: First Health Commercial |
$535.64
|
| Rate for Payer: Humana Commercial |
$479.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$462.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$496.17
|
| Rate for Payer: Ohio Health Group HMO |
$422.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$451.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.04
|
| Rate for Payer: PHCS Commercial |
$541.28
|
| Rate for Payer: United Healthcare All Payer |
$496.17
|
|
|
INFANRIX VACC (DTAP) 0.5ML
|
Facility
|
OP
|
$183.34
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
25000035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$176.01 |
| Rate for Payer: Aetna Commercial |
$141.17
|
| Rate for Payer: Anthem Medicaid |
$63.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.01
|
| Rate for Payer: Cash Price |
$91.67
|
| Rate for Payer: Cigna Commercial |
$152.17
|
| Rate for Payer: First Health Commercial |
$174.17
|
| Rate for Payer: Humana Commercial |
$155.84
|
| Rate for Payer: Humana KY Medicaid |
$63.05
|
| Rate for Payer: Kentucky WC Medicaid |
$63.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.34
|
| Rate for Payer: Ohio Health Group HMO |
$137.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$146.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.50
|
| Rate for Payer: PHCS Commercial |
$176.01
|
| Rate for Payer: United Healthcare All Payer |
$161.34
|
|
|
INFANRIX VACC (DTAP) 0.5ML
|
Facility
|
IP
|
$183.34
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
25000035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$176.01 |
| Rate for Payer: Aetna Commercial |
$141.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.01
|
| Rate for Payer: Cash Price |
$91.67
|
| Rate for Payer: Cigna Commercial |
$152.17
|
| Rate for Payer: First Health Commercial |
$174.17
|
| Rate for Payer: Humana Commercial |
$155.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.34
|
| Rate for Payer: Ohio Health Group HMO |
$137.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$146.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.50
|
| Rate for Payer: PHCS Commercial |
$176.01
|
| Rate for Payer: United Healthcare All Payer |
$161.34
|
|
|
INFANT MYLICON GAS DROPS 15ML
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
25003783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
INFANT MYLICON GAS DROPS 15ML
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
25003783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
INFANTS GAS RELIEF DROP (30ML)
|
Facility
|
OP
|
$5.44
|
|
|
Service Code
|
NDC 46122054703
|
| Hospital Charge Code |
25000780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: Anthem Medicaid |
$1.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.24
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna Commercial |
$4.52
|
| Rate for Payer: First Health Commercial |
$5.17
|
| Rate for Payer: Humana Commercial |
$4.62
|
| Rate for Payer: Humana KY Medicaid |
$1.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.79
|
| Rate for Payer: Ohio Health Group HMO |
$4.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.75
|
| Rate for Payer: PHCS Commercial |
$5.22
|
| Rate for Payer: United Healthcare All Payer |
$4.79
|
|
|
INFANTS GAS RELIEF DROP (30ML)
|
Facility
|
IP
|
$5.44
|
|
|
Service Code
|
NDC 46122054703
|
| Hospital Charge Code |
25000780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.24
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna Commercial |
$4.52
|
| Rate for Payer: First Health Commercial |
$5.17
|
| Rate for Payer: Humana Commercial |
$4.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.79
|
| Rate for Payer: Ohio Health Group HMO |
$4.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.75
|
| Rate for Payer: PHCS Commercial |
$5.22
|
| Rate for Payer: United Healthcare All Payer |
$4.79
|
|
|
INFED IRONDEX 50 MG/100MG/2ML
|
Facility
|
OP
|
$189.82
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
25002161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$182.23 |
| Rate for Payer: Aetna Commercial |
$146.16
|
| Rate for Payer: Anthem Medicaid |
$65.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.34
|
| Rate for Payer: Cash Price |
$94.91
|
| Rate for Payer: Cash Price |
$94.91
|
| Rate for Payer: Cigna Commercial |
$157.55
|
| Rate for Payer: First Health Commercial |
$180.33
|
| Rate for Payer: Humana Commercial |
$161.35
|
| Rate for Payer: Humana KY Medicaid |
$65.28
|
| Rate for Payer: Humana Medicare Advantage |
$18.03
|
| Rate for Payer: Kentucky WC Medicaid |
$65.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.04
|
| Rate for Payer: Ohio Health Group HMO |
$142.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.98
|
| Rate for Payer: PHCS Commercial |
$182.23
|
| Rate for Payer: United Healthcare All Payer |
$167.04
|
|
