|
IV NCHEMO ADDTL DRUG
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem Medicaid |
$74.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$57.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.46
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Humana KY Medicaid |
$74.97
|
| Rate for Payer: Humana Medicare Advantage |
$41.08
|
| Rate for Payer: Kentucky WC Medicaid |
$75.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
IV NCHEMO ADDTL DRUG
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
IV NCHEMO ADDTL DRUG(T
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
260T0010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem Medicaid |
$74.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$57.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.46
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Humana KY Medicaid |
$74.97
|
| Rate for Payer: Humana Medicare Advantage |
$41.08
|
| Rate for Payer: Kentucky WC Medicaid |
$75.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
IV NCHEMO ADDTL DRUG(T
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
260T0010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
IVPYELOGRAM LIMITED
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
32000143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
IVPYELOGRAM LIMITED
|
Professional
|
Both
|
$780.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
32000143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$31.17 |
| Max. Negotiated Rate |
$780.00 |
| Rate for Payer: Aetna Commercial |
$165.46
|
| Rate for Payer: Anthem Medicaid |
$66.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$780.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$143.63
|
| Rate for Payer: Healthspan PPO |
$155.04
|
| Rate for Payer: Humana Medicaid |
$66.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$31.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.93
|
| Rate for Payer: Molina Healthcare Passport |
$66.60
|
| Rate for Payer: Multiplan PHCS |
$468.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$546.00
|
| Rate for Payer: UHCCP Medicaid |
$273.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$67.27
|
|
|
IVPYELOGRAM LIMITED
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
32000143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem Medicaid |
$268.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Humana KY Medicaid |
$268.24
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$270.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$273.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
IVPYELOGRAM LIMITED(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
320P0143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$165.46 |
| Rate for Payer: Aetna Commercial |
$165.46
|
| Rate for Payer: Anthem Medicaid |
$66.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$143.63
|
| Rate for Payer: Healthspan PPO |
$155.04
|
| Rate for Payer: Humana Medicaid |
$66.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$31.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.93
|
| Rate for Payer: Molina Healthcare Passport |
$66.60
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$67.27
|
|
|
IVPYELOGRAM LIMITED(T
|
Facility
|
IP
|
$705.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
320T0143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Aetna Commercial |
$542.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$549.90
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cigna Commercial |
$585.15
|
| Rate for Payer: First Health Commercial |
$669.75
|
| Rate for Payer: Humana Commercial |
$599.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$578.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$520.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$211.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$620.40
|
| Rate for Payer: Ohio Health Group HMO |
$528.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$218.55
|
| Rate for Payer: PHCS Commercial |
$676.80
|
| Rate for Payer: United Healthcare All Payer |
$620.40
|
|
|
IVPYELOGRAM LIMITED(T
|
Facility
|
OP
|
$705.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
320T0143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Aetna Commercial |
$542.85
|
| Rate for Payer: Anthem Medicaid |
$242.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$549.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cigna Commercial |
$585.15
|
| Rate for Payer: First Health Commercial |
$669.75
|
| Rate for Payer: Humana Commercial |
$599.25
|
| Rate for Payer: Humana KY Medicaid |
$242.45
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$244.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$578.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$520.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$247.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$620.40
|
| Rate for Payer: Ohio Health Group HMO |
$528.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$218.55
|
| Rate for Payer: PHCS Commercial |
$676.80
|
| Rate for Payer: United Healthcare All Payer |
$620.40
|
|
|
IV SEQ SAME DRUG >30 MIN EA
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
26000011
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$141.68
|
| Rate for Payer: Anthem Medicaid |
$63.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: First Health Commercial |
$174.80
|
| Rate for Payer: Humana Commercial |
$156.40
|
| Rate for Payer: Humana KY Medicaid |
$63.28
|
| Rate for Payer: Kentucky WC Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.92
|
| Rate for Payer: Ohio Health Group HMO |
$138.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.04
|
| Rate for Payer: PHCS Commercial |
$176.64
|
| Rate for Payer: United Healthcare All Payer |
$161.92
|
|
|
IV SEQ SAME DRUG >30 MIN EA
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
26000011
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$141.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: First Health Commercial |
$174.80
|
| Rate for Payer: Humana Commercial |
$156.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.92
|
| Rate for Payer: Ohio Health Group HMO |
$138.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.04
|
| Rate for Payer: PHCS Commercial |
$176.64
|
| Rate for Payer: United Healthcare All Payer |
$161.92
|
|
|
IXEMPRA 1 MG (15MG VIAL)
|
Facility
|
OP
|
$10,764.08
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.07 |
| Max. Negotiated Rate |
$10,333.52 |
| Rate for Payer: Aetna Commercial |
$8,288.34
|
| Rate for Payer: Anthem Medicaid |
$3,701.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$128.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,395.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$179.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$172.90
|
| Rate for Payer: Cash Price |
$5,382.04
|
| Rate for Payer: Cash Price |
$5,382.04
|
| Rate for Payer: Cigna Commercial |
$8,934.19
|
| Rate for Payer: First Health Commercial |
$10,225.88
|
| Rate for Payer: Humana Commercial |
$9,149.47
|
| Rate for Payer: Humana KY Medicaid |
$3,701.77
|
| Rate for Payer: Humana Medicare Advantage |
$128.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,739.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,826.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,943.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,776.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,472.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,073.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,152.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,399.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,336.86
|
| Rate for Payer: PHCS Commercial |
$10,333.52
|
| Rate for Payer: United Healthcare All Payer |
$9,472.39
|
|
|
IXEMPRA 1 MG (15MG VIAL)
|
Facility
|
IP
|
$10,764.08
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,399.33 |
| Max. Negotiated Rate |
$10,333.52 |
| Rate for Payer: Aetna Commercial |
$8,288.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,395.98
|
| Rate for Payer: Cash Price |
$5,382.04
|
| Rate for Payer: Cigna Commercial |
$8,934.19
|
| Rate for Payer: First Health Commercial |
$10,225.88
|
| Rate for Payer: Humana Commercial |
$9,149.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,826.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,943.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,229.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,472.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,073.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,152.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,399.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,336.86
|
| Rate for Payer: PHCS Commercial |
$10,333.52
|
| Rate for Payer: United Healthcare All Payer |
$9,472.39
|
|
|
IXEMPRA 1MG (45MG VIAL)
|
Facility
|
OP
|
$32,292.23
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.07 |
| Max. Negotiated Rate |
$31,000.54 |
| Rate for Payer: Aetna Commercial |
$24,865.02
|
| Rate for Payer: Anthem Medicaid |
$11,105.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$128.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,187.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$179.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$172.90
|
| Rate for Payer: Cash Price |
$16,146.11
|
| Rate for Payer: Cash Price |
$16,146.11
|
| Rate for Payer: Cigna Commercial |
$26,802.55
|
| Rate for Payer: First Health Commercial |
$30,677.62
|
| Rate for Payer: Humana Commercial |
$27,448.40
|
| Rate for Payer: Humana KY Medicaid |
$11,105.30
|
| Rate for Payer: Humana Medicare Advantage |
$128.07
|
| Rate for Payer: Kentucky WC Medicaid |
$11,218.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,479.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,831.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,328.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,417.16
|
| Rate for Payer: Ohio Health Group HMO |
$24,219.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,458.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,197.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,010.59
|
| Rate for Payer: PHCS Commercial |
$31,000.54
|
| Rate for Payer: United Healthcare All Payer |
$28,417.16
|
|
|
IXEMPRA 1MG (45MG VIAL)
|
Facility
|
IP
|
$32,292.23
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,197.99 |
| Max. Negotiated Rate |
$31,000.54 |
| Rate for Payer: Aetna Commercial |
$24,865.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,187.94
|
| Rate for Payer: Cash Price |
$16,146.11
|
| Rate for Payer: Cigna Commercial |
$26,802.55
|
| Rate for Payer: First Health Commercial |
$30,677.62
|
| Rate for Payer: Humana Commercial |
$27,448.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,479.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,831.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,687.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,417.16
|
| Rate for Payer: Ohio Health Group HMO |
$24,219.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,458.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,197.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,010.59
|
| Rate for Payer: PHCS Commercial |
$31,000.54
|
| Rate for Payer: United Healthcare All Payer |
$28,417.16
|
|
|
JACKY RADIAL 5FR
|
Facility
|
IP
|
$757.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.48 |
| Max. Negotiated Rate |
$727.20 |
| Rate for Payer: Aetna Commercial |
$583.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$590.85
|
| Rate for Payer: Cash Price |
$378.75
|
| Rate for Payer: Cigna Commercial |
$628.72
|
| Rate for Payer: First Health Commercial |
$719.62
|
| Rate for Payer: Humana Commercial |
$643.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$621.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$666.60
|
| Rate for Payer: Ohio Health Group HMO |
$568.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.82
|
| Rate for Payer: PHCS Commercial |
$727.20
|
| Rate for Payer: United Healthcare All Payer |
$666.60
|
|
|
JACKY RADIAL 5FR
|
Facility
|
OP
|
$757.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.48 |
| Max. Negotiated Rate |
$727.20 |
| Rate for Payer: Aetna Commercial |
$583.28
|
| Rate for Payer: Anthem Medicaid |
$260.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$590.85
|
| Rate for Payer: Cash Price |
$378.75
|
| Rate for Payer: Cigna Commercial |
$628.72
|
| Rate for Payer: First Health Commercial |
$719.62
|
| Rate for Payer: Humana Commercial |
$643.88
|
| Rate for Payer: Humana KY Medicaid |
$260.50
|
| Rate for Payer: Kentucky WC Medicaid |
$263.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$621.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$265.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$666.60
|
| Rate for Payer: Ohio Health Group HMO |
$568.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.82
|
| Rate for Payer: PHCS Commercial |
$727.20
|
| Rate for Payer: United Healthcare All Payer |
$666.60
|
|
|
JACKY RADIAL CATH
|
Facility
|
OP
|
$757.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.48 |
| Max. Negotiated Rate |
$727.20 |
| Rate for Payer: Aetna Commercial |
$583.28
|
| Rate for Payer: Anthem Medicaid |
$260.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$590.85
|
| Rate for Payer: Cash Price |
$378.75
|
| Rate for Payer: Cigna Commercial |
$628.72
|
| Rate for Payer: First Health Commercial |
$719.62
|
| Rate for Payer: Humana Commercial |
$643.88
|
| Rate for Payer: Humana KY Medicaid |
$260.50
|
| Rate for Payer: Kentucky WC Medicaid |
$263.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$621.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$265.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$666.60
|
| Rate for Payer: Ohio Health Group HMO |
$568.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.82
|
| Rate for Payer: PHCS Commercial |
$727.20
|
| Rate for Payer: United Healthcare All Payer |
$666.60
|
|
|
JACKY RADIAL CATH
|
Facility
|
IP
|
$757.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.48 |
| Max. Negotiated Rate |
$727.20 |
| Rate for Payer: Aetna Commercial |
$583.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$590.85
|
| Rate for Payer: Cash Price |
$378.75
|
| Rate for Payer: Cigna Commercial |
$628.72
|
| Rate for Payer: First Health Commercial |
$719.62
|
| Rate for Payer: Humana Commercial |
$643.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$621.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$666.60
|
| Rate for Payer: Ohio Health Group HMO |
$568.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.82
|
| Rate for Payer: PHCS Commercial |
$727.20
|
| Rate for Payer: United Healthcare All Payer |
$666.60
|
|
|
JAGTOME
|
Facility
|
OP
|
$3,610.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.36 |
| Max. Negotiated Rate |
$3,466.08 |
| Rate for Payer: Aetna Commercial |
$2,780.08
|
| Rate for Payer: Anthem Medicaid |
$1,241.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,816.19
|
| Rate for Payer: Cash Price |
$1,805.25
|
| Rate for Payer: Cigna Commercial |
$2,996.72
|
| Rate for Payer: First Health Commercial |
$3,429.98
|
| Rate for Payer: Humana Commercial |
$3,068.92
|
| Rate for Payer: Humana KY Medicaid |
$1,241.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,254.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,960.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,664.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,083.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,266.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,177.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,707.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,119.26
|
| Rate for Payer: PHCS Commercial |
$3,466.08
|
| Rate for Payer: United Healthcare All Payer |
$3,177.24
|
|
|
JAGTOME
|
Facility
|
IP
|
$3,610.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.36 |
| Max. Negotiated Rate |
$3,466.08 |
| Rate for Payer: Aetna Commercial |
$2,780.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,816.19
|
| Rate for Payer: Cash Price |
$1,805.25
|
| Rate for Payer: Cigna Commercial |
$2,996.72
|
| Rate for Payer: First Health Commercial |
$3,429.98
|
| Rate for Payer: Humana Commercial |
$3,068.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,960.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,664.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,083.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,177.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,707.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,119.26
|
| Rate for Payer: PHCS Commercial |
$3,466.08
|
| Rate for Payer: United Healthcare All Payer |
$3,177.24
|
|
|
JAGWIRE GUIDEWIRE .035*260 ST
|
Facility
|
OP
|
$1,912.28
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.60 |
| Max. Negotiated Rate |
$1,835.79 |
| Rate for Payer: Aetna Commercial |
$1,472.46
|
| Rate for Payer: Anthem Medicaid |
$657.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,491.58
|
| Rate for Payer: Cash Price |
$956.14
|
| Rate for Payer: Cigna Commercial |
$1,587.19
|
| Rate for Payer: First Health Commercial |
$1,816.67
|
| Rate for Payer: Humana Commercial |
$1,625.44
|
| Rate for Payer: Humana KY Medicaid |
$657.63
|
| Rate for Payer: Kentucky WC Medicaid |
$664.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,568.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,411.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$670.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,682.81
|
| Rate for Payer: Ohio Health Group HMO |
$1,434.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.81
|
| Rate for Payer: PHCS Commercial |
$1,835.79
|
| Rate for Payer: United Healthcare All Payer |
$1,682.81
|
|
|
JAGWIRE GUIDEWIRE .035*260 ST
|
Facility
|
IP
|
$1,912.28
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.60 |
| Max. Negotiated Rate |
$1,835.79 |
| Rate for Payer: Aetna Commercial |
$1,472.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,491.58
|
| Rate for Payer: Cash Price |
$956.14
|
| Rate for Payer: Cigna Commercial |
$1,587.19
|
| Rate for Payer: First Health Commercial |
$1,816.67
|
| Rate for Payer: Humana Commercial |
$1,625.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,568.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,411.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,682.81
|
| Rate for Payer: Ohio Health Group HMO |
$1,434.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.81
|
| Rate for Payer: PHCS Commercial |
$1,835.79
|
| Rate for Payer: United Healthcare All Payer |
$1,682.81
|
|
|
JAGWIR GUIDWIR .035*260 ANGLE
|
Facility
|
OP
|
$1,717.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.28 |
| Max. Negotiated Rate |
$1,648.80 |
| Rate for Payer: Aetna Commercial |
$1,322.48
|
| Rate for Payer: Anthem Medicaid |
$590.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,339.65
|
| Rate for Payer: Cash Price |
$858.75
|
| Rate for Payer: Cigna Commercial |
$1,425.52
|
| Rate for Payer: First Health Commercial |
$1,631.62
|
| Rate for Payer: Humana Commercial |
$1,459.88
|
| Rate for Payer: Humana KY Medicaid |
$590.65
|
| Rate for Payer: Kentucky WC Medicaid |
$596.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$602.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$223.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$532.42
|
| Rate for Payer: PHCS Commercial |
$1,648.80
|
| Rate for Payer: United Healthcare All Payer |
$1,511.40
|
|
