|
ISORDIL (ISOSORBIDE) 20MG/1TAB
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 68084008301
|
| Hospital Charge Code |
25000801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem Medicaid |
$1.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.99
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.24
|
| Rate for Payer: First Health Commercial |
$4.85
|
| Rate for Payer: Humana Commercial |
$4.34
|
| Rate for Payer: Humana KY Medicaid |
$1.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.50
|
| Rate for Payer: Ohio Health Group HMO |
$3.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.53
|
| Rate for Payer: PHCS Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Payer |
$4.50
|
|
|
ISORDIL (ISOSORBIDE) 20MG/1TAB
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 68084008301
|
| Hospital Charge Code |
25000801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.99
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.24
|
| Rate for Payer: First Health Commercial |
$4.85
|
| Rate for Payer: Humana Commercial |
$4.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.50
|
| Rate for Payer: Ohio Health Group HMO |
$3.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.53
|
| Rate for Payer: PHCS Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Payer |
$4.50
|
|
|
ISORDIL (ISOSORBIDE) 5MG/1TAB
|
Facility
|
OP
|
$5.09
|
|
|
Service Code
|
NDC 50268044715
|
| Hospital Charge Code |
25000802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Humana KY Medicaid |
$1.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
ISORDIL (ISOSORBIDE) 5MG/1TAB
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 50268044715
|
| Hospital Charge Code |
25000802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
ISOVUE 250 51% 1ML [100ML SDV]
|
Facility
|
OP
|
$425.01
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.01 |
| Rate for Payer: Aetna Commercial |
$327.26
|
| Rate for Payer: Anthem Medicaid |
$146.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.51
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.76
|
| Rate for Payer: First Health Commercial |
$403.76
|
| Rate for Payer: Humana Commercial |
$361.26
|
| Rate for Payer: Humana KY Medicaid |
$146.16
|
| Rate for Payer: Kentucky WC Medicaid |
$147.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.01
|
| Rate for Payer: Ohio Health Group HMO |
$318.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.26
|
| Rate for Payer: PHCS Commercial |
$408.01
|
| Rate for Payer: United Healthcare All Payer |
$374.01
|
|
|
ISOVUE 250 51% 1ML [100ML SDV]
|
Facility
|
IP
|
$425.01
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.01 |
| Rate for Payer: Aetna Commercial |
$327.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.51
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.76
|
| Rate for Payer: First Health Commercial |
$403.76
|
| Rate for Payer: Humana Commercial |
$361.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.01
|
| Rate for Payer: Ohio Health Group HMO |
$318.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.26
|
| Rate for Payer: PHCS Commercial |
$408.01
|
| Rate for Payer: United Healthcare All Payer |
$374.01
|
|
|
ISOVUE300 61% 1ML (100ML SDV)
|
Facility
|
IP
|
$430.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002742
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.24 |
| Max. Negotiated Rate |
$413.57 |
| Rate for Payer: Aetna Commercial |
$331.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$336.02
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$357.56
|
| Rate for Payer: First Health Commercial |
$409.26
|
| Rate for Payer: Humana Commercial |
$366.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$353.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$379.10
|
| Rate for Payer: Ohio Health Group HMO |
$323.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.25
|
| Rate for Payer: PHCS Commercial |
$413.57
|
| Rate for Payer: United Healthcare All Payer |
$379.10
|
|
|
ISOVUE300 61% 1ML (100ML SDV)
|
Facility
|
OP
|
$430.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002742
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.24 |
| Max. Negotiated Rate |
$413.57 |
| Rate for Payer: Aetna Commercial |
$331.72
|
| Rate for Payer: Anthem Medicaid |
$148.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$336.02
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$357.56
|
| Rate for Payer: First Health Commercial |
$409.26
|
| Rate for Payer: Humana Commercial |
$366.18
|
| Rate for Payer: Humana KY Medicaid |
$148.15
|
| Rate for Payer: Kentucky WC Medicaid |
$149.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$353.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$151.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$379.10
|
| Rate for Payer: Ohio Health Group HMO |
$323.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.25
|
| Rate for Payer: PHCS Commercial |
$413.57
|
| Rate for Payer: United Healthcare All Payer |
$379.10
|
|
|
ISOVUE 300 61% 1ML (200ML SDV)
|
Facility
|
IP
|
$931.70
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$279.51 |
| Max. Negotiated Rate |
$894.43 |
| Rate for Payer: Aetna Commercial |
$717.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.73
|
| Rate for Payer: Cash Price |
$465.85
|
| Rate for Payer: Cigna Commercial |
$773.31
|
| Rate for Payer: First Health Commercial |
$885.12
|
| Rate for Payer: Humana Commercial |
$791.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.90
|
| Rate for Payer: Ohio Health Group HMO |
$698.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$745.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$810.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.87
|
| Rate for Payer: PHCS Commercial |
$894.43
|
| Rate for Payer: United Healthcare All Payer |
$819.90
|
|
|
ISOVUE 300 61% 1ML (200ML SDV)
|
Facility
|
OP
|
$931.70
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$279.51 |
| Max. Negotiated Rate |
$894.43 |
| Rate for Payer: Aetna Commercial |
$717.41
|
| Rate for Payer: Anthem Medicaid |
$320.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.73
|
| Rate for Payer: Cash Price |
$465.85
|
| Rate for Payer: Cigna Commercial |
$773.31
|
| Rate for Payer: First Health Commercial |
$885.12
|
| Rate for Payer: Humana Commercial |
$791.95
|
| Rate for Payer: Humana KY Medicaid |
$320.41
|
| Rate for Payer: Kentucky WC Medicaid |
$323.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.90
|
| Rate for Payer: Ohio Health Group HMO |
$698.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$745.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$810.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.87
|
| Rate for Payer: PHCS Commercial |
$894.43
|
| Rate for Payer: United Healthcare All Payer |
$819.90
|
|
|
ISOVUE-370 150 ML BTL (per mL)
|
Facility
|
IP
|
$647.82
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003985
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.35 |
| Max. Negotiated Rate |
$621.91 |
| Rate for Payer: Aetna Commercial |
$498.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$505.30
|
| Rate for Payer: Cash Price |
$323.91
|
| Rate for Payer: Cigna Commercial |
$537.69
|
| Rate for Payer: First Health Commercial |
$615.43
|
| Rate for Payer: Humana Commercial |
$550.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$531.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$478.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$570.08
|
| Rate for Payer: Ohio Health Group HMO |
$485.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$518.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$563.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.00
|
| Rate for Payer: PHCS Commercial |
$621.91
|
| Rate for Payer: United Healthcare All Payer |
$570.08
|
|
|
ISOVUE-370 150 ML BTL (per mL)
|
Facility
|
OP
|
$647.82
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003985
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.35 |
| Max. Negotiated Rate |
$621.91 |
| Rate for Payer: Aetna Commercial |
$498.82
|
| Rate for Payer: Anthem Medicaid |
$222.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$505.30
|
| Rate for Payer: Cash Price |
$323.91
|
| Rate for Payer: Cigna Commercial |
$537.69
|
| Rate for Payer: First Health Commercial |
$615.43
|
| Rate for Payer: Humana Commercial |
$550.65
|
| Rate for Payer: Humana KY Medicaid |
$222.79
|
| Rate for Payer: Kentucky WC Medicaid |
$225.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$531.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$478.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$227.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$570.08
|
| Rate for Payer: Ohio Health Group HMO |
$485.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$518.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$563.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.00
|
| Rate for Payer: PHCS Commercial |
$621.91
|
| Rate for Payer: United Healthcare All Payer |
$570.08
|
|
|
ISOVUE-370 75 ML BTL (per mL)
|
Facility
|
IP
|
$326.97
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.09 |
| Max. Negotiated Rate |
$313.89 |
| Rate for Payer: Aetna Commercial |
$251.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.04
|
| Rate for Payer: Cash Price |
$163.49
|
| Rate for Payer: Cigna Commercial |
$271.39
|
| Rate for Payer: First Health Commercial |
$310.62
|
| Rate for Payer: Humana Commercial |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.73
|
| Rate for Payer: Ohio Health Group HMO |
$245.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.61
|
| Rate for Payer: PHCS Commercial |
$313.89
|
| Rate for Payer: United Healthcare All Payer |
$287.73
|
|
|
ISOVUE-370 75 ML BTL (per mL)
|
Facility
|
OP
|
$326.97
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.09 |
| Max. Negotiated Rate |
$313.89 |
| Rate for Payer: Aetna Commercial |
$251.77
|
| Rate for Payer: Anthem Medicaid |
$112.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.04
|
| Rate for Payer: Cash Price |
$163.49
|
| Rate for Payer: Cigna Commercial |
$271.39
|
| Rate for Payer: First Health Commercial |
$310.62
|
| Rate for Payer: Humana Commercial |
$277.92
|
| Rate for Payer: Humana KY Medicaid |
$112.44
|
| Rate for Payer: Kentucky WC Medicaid |
$113.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.73
|
| Rate for Payer: Ohio Health Group HMO |
$245.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.61
|
| Rate for Payer: PHCS Commercial |
$313.89
|
| Rate for Payer: United Healthcare All Payer |
$287.73
|
|
|
ISOVUE 370 76%EA 500ML VIAL
|
Facility
|
IP
|
$2,179.15
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$653.75 |
| Max. Negotiated Rate |
$2,091.98 |
| Rate for Payer: Aetna Commercial |
$1,677.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,699.74
|
| Rate for Payer: Cash Price |
$1,089.58
|
| Rate for Payer: Cigna Commercial |
$1,808.69
|
| Rate for Payer: First Health Commercial |
$2,070.19
|
| Rate for Payer: Humana Commercial |
$1,852.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,786.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$653.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,917.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,634.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,743.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,895.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.61
|
| Rate for Payer: PHCS Commercial |
$2,091.98
|
| Rate for Payer: United Healthcare All Payer |
$1,917.65
|
|
|
ISOVUE 370 76%EA 500ML VIAL
|
Facility
|
OP
|
$2,179.15
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$653.75 |
| Max. Negotiated Rate |
$2,091.98 |
| Rate for Payer: Aetna Commercial |
$1,677.95
|
| Rate for Payer: Anthem Medicaid |
$749.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,699.74
|
| Rate for Payer: Cash Price |
$1,089.58
|
| Rate for Payer: Cigna Commercial |
$1,808.69
|
| Rate for Payer: First Health Commercial |
$2,070.19
|
| Rate for Payer: Humana Commercial |
$1,852.28
|
| Rate for Payer: Humana KY Medicaid |
$749.41
|
| Rate for Payer: Kentucky WC Medicaid |
$757.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,786.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$653.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$764.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,917.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,634.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,743.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,895.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.61
|
| Rate for Payer: PHCS Commercial |
$2,091.98
|
| Rate for Payer: United Healthcare All Payer |
$1,917.65
|
|
|
ISOVUE370 76% EAML 10X100ML VL
|
Facility
|
IP
|
$435.83
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.75 |
| Max. Negotiated Rate |
$418.40 |
| Rate for Payer: Aetna Commercial |
$335.59
|
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$339.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$217.92
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$361.74
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: First Health Commercial |
$414.04
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana Commercial |
$370.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$357.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$383.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$326.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$379.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.72
|
| Rate for Payer: PHCS Commercial |
$418.40
|
| Rate for Payer: PHCS Commercial |
$4.19
|
| Rate for Payer: United Healthcare All Payer |
$383.53
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
|
|
ISOVUE370 76% EAML 10X100ML VL
|
Facility
|
OP
|
$435.83
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.75 |
| Max. Negotiated Rate |
$418.40 |
| Rate for Payer: Aetna Commercial |
$335.59
|
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$149.88
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$339.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$217.92
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: Cigna Commercial |
$361.74
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: First Health Commercial |
$414.04
|
| Rate for Payer: Humana Commercial |
$370.46
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$149.88
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$151.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$357.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$152.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$383.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$326.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$379.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.01
|
| Rate for Payer: PHCS Commercial |
$4.19
|
| Rate for Payer: PHCS Commercial |
$418.40
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
| Rate for Payer: United Healthcare All Payer |
$383.53
|
|
|
ISOVUE-M 200 10 ML VIAL
|
Facility
|
IP
|
$103.12
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
25003975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna Commercial |
$79.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.43
|
| Rate for Payer: Cash Price |
$51.56
|
| Rate for Payer: Cigna Commercial |
$85.59
|
| Rate for Payer: First Health Commercial |
$97.96
|
| Rate for Payer: Humana Commercial |
$87.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$90.75
|
| Rate for Payer: Ohio Health Group HMO |
$77.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.15
|
| Rate for Payer: PHCS Commercial |
$99.00
|
| Rate for Payer: United Healthcare All Payer |
$90.75
|
|
|
ISOVUE-M 200 10 ML VIAL
|
Facility
|
OP
|
$103.12
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
25003975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna Commercial |
$79.40
|
| Rate for Payer: Anthem Medicaid |
$35.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.43
|
| Rate for Payer: Cash Price |
$51.56
|
| Rate for Payer: Cigna Commercial |
$85.59
|
| Rate for Payer: First Health Commercial |
$97.96
|
| Rate for Payer: Humana Commercial |
$87.65
|
| Rate for Payer: Humana KY Medicaid |
$35.46
|
| Rate for Payer: Kentucky WC Medicaid |
$35.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$90.75
|
| Rate for Payer: Ohio Health Group HMO |
$77.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.15
|
| Rate for Payer: PHCS Commercial |
$99.00
|
| Rate for Payer: United Healthcare All Payer |
$90.75
|
|
|
ISOVUE-M 200 41% 1ML (20MLSDV)
|
Facility
|
IP
|
$165.54
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.66 |
| Max. Negotiated Rate |
$158.92 |
| Rate for Payer: Aetna Commercial |
$127.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$129.12
|
| Rate for Payer: Cash Price |
$82.77
|
| Rate for Payer: Cigna Commercial |
$137.40
|
| Rate for Payer: First Health Commercial |
$157.26
|
| Rate for Payer: Humana Commercial |
$140.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$145.68
|
| Rate for Payer: Ohio Health Group HMO |
$124.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$144.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.22
|
| Rate for Payer: PHCS Commercial |
$158.92
|
| Rate for Payer: United Healthcare All Payer |
$145.68
|
|
|
ISOVUE-M 200 41% 1ML (20MLSDV)
|
Facility
|
OP
|
$165.54
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.66 |
| Max. Negotiated Rate |
$158.92 |
| Rate for Payer: Aetna Commercial |
$127.47
|
| Rate for Payer: Anthem Medicaid |
$56.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$129.12
|
| Rate for Payer: Cash Price |
$82.77
|
| Rate for Payer: Cigna Commercial |
$137.40
|
| Rate for Payer: First Health Commercial |
$157.26
|
| Rate for Payer: Humana Commercial |
$140.71
|
| Rate for Payer: Humana KY Medicaid |
$56.93
|
| Rate for Payer: Kentucky WC Medicaid |
$57.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$145.68
|
| Rate for Payer: Ohio Health Group HMO |
$124.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$144.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.22
|
| Rate for Payer: PHCS Commercial |
$158.92
|
| Rate for Payer: United Healthcare All Payer |
$145.68
|
|
|
ISOVUE-M 300 1ML [61% 15ML V]
|
Facility
|
OP
|
$143.62
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.09 |
| Max. Negotiated Rate |
$137.88 |
| Rate for Payer: Aetna Commercial |
$110.59
|
| Rate for Payer: Anthem Medicaid |
$49.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.02
|
| Rate for Payer: Cash Price |
$71.81
|
| Rate for Payer: Cigna Commercial |
$119.20
|
| Rate for Payer: First Health Commercial |
$136.44
|
| Rate for Payer: Humana Commercial |
$122.08
|
| Rate for Payer: Humana KY Medicaid |
$49.39
|
| Rate for Payer: Kentucky WC Medicaid |
$49.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.39
|
| Rate for Payer: Ohio Health Group HMO |
$107.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$114.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.10
|
| Rate for Payer: PHCS Commercial |
$137.88
|
| Rate for Payer: United Healthcare All Payer |
$126.39
|
|
|
ISOVUE-M 300 1ML [61% 15ML V]
|
Facility
|
IP
|
$143.62
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.09 |
| Max. Negotiated Rate |
$137.88 |
| Rate for Payer: Aetna Commercial |
$110.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.02
|
| Rate for Payer: Cash Price |
$71.81
|
| Rate for Payer: Cigna Commercial |
$119.20
|
| Rate for Payer: First Health Commercial |
$136.44
|
| Rate for Payer: Humana Commercial |
$122.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.39
|
| Rate for Payer: Ohio Health Group HMO |
$107.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$114.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.10
|
| Rate for Payer: PHCS Commercial |
$137.88
|
| Rate for Payer: United Healthcare All Payer |
$126.39
|
|
|
ISOVUE MP37076%PERML10X200MLVL
|
Facility
|
OP
|
$871.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25002741
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$261.36 |
| Max. Negotiated Rate |
$836.35 |
| Rate for Payer: Aetna Commercial |
$670.82
|
| Rate for Payer: Anthem Medicaid |
$299.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$679.54
|
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$723.10
|
| Rate for Payer: First Health Commercial |
$827.64
|
| Rate for Payer: Humana Commercial |
$740.52
|
| Rate for Payer: Humana KY Medicaid |
$299.61
|
| Rate for Payer: Kentucky WC Medicaid |
$302.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$714.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$642.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$261.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$305.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$766.66
|
| Rate for Payer: Ohio Health Group HMO |
$653.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$696.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$757.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$601.13
|
| Rate for Payer: PHCS Commercial |
$836.35
|
| Rate for Payer: United Healthcare All Payer |
$766.66
|
|
