|
IV INJECTION
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
26000009
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem Medicaid |
$104.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$194.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$272.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$262.80
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Humana KY Medicaid |
$104.55
|
| Rate for Payer: Humana Medicare Advantage |
$194.67
|
| Rate for Payer: Kentucky WC Medicaid |
$105.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$233.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
IV INJECTION(T
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
260T0009
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$91.20 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
IV INJECTION(T
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
260T0009
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem Medicaid |
$104.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$194.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$272.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$262.80
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Humana KY Medicaid |
$104.55
|
| Rate for Payer: Humana Medicare Advantage |
$194.67
|
| Rate for Payer: Kentucky WC Medicaid |
$105.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$233.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
IV NCHEMO ADDTL DRUG
|
Professional
|
Both
|
$231.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.29 |
| Max. Negotiated Rate |
$138.60 |
| Rate for Payer: Aetna Commercial |
$36.45
|
| Rate for Payer: Ambetter Exchange |
$13.29
|
| Rate for Payer: Anthem Medicaid |
$18.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$13.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$13.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.95
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$32.03
|
| Rate for Payer: Healthspan PPO |
$34.16
|
| Rate for Payer: Humana Medicaid |
$18.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$13.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.37
|
| Rate for Payer: Molina Healthcare Passport |
$18.99
|
| Rate for Payer: Multiplan PHCS |
$138.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.28
|
| Rate for Payer: UHCCP Medicaid |
$80.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$13.29
|
|
|
IV NCHEMO ADDTL DRUG
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$221.76 |
| Rate for Payer: Aetna Commercial |
$177.87
|
| Rate for Payer: Anthem Medicaid |
$79.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$42.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$59.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.55
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$191.73
|
| Rate for Payer: First Health Commercial |
$219.45
|
| Rate for Payer: Humana Commercial |
$196.35
|
| Rate for Payer: Humana KY Medicaid |
$79.44
|
| Rate for Payer: Humana Medicare Advantage |
$42.63
|
| Rate for Payer: Kentucky WC Medicaid |
$80.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$189.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$170.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$81.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$203.28
|
| Rate for Payer: Ohio Health Group HMO |
$173.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$159.39
|
| Rate for Payer: PHCS Commercial |
$221.76
|
| Rate for Payer: United Healthcare All Payer |
$203.28
|
|
|
IV NCHEMO ADDTL DRUG
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$221.76 |
| Rate for Payer: Aetna Commercial |
$177.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.18
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$191.73
|
| Rate for Payer: First Health Commercial |
$219.45
|
| Rate for Payer: Humana Commercial |
$196.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$189.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$170.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$203.28
|
| Rate for Payer: Ohio Health Group HMO |
$173.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$159.39
|
| Rate for Payer: PHCS Commercial |
$221.76
|
| Rate for Payer: United Healthcare All Payer |
$203.28
|
|
|
IV NCHEMO ADDTL DRUG(T
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
260T0010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$221.76 |
| Rate for Payer: Aetna Commercial |
$177.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.18
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$191.73
|
| Rate for Payer: First Health Commercial |
$219.45
|
| Rate for Payer: Humana Commercial |
$196.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$189.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$170.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$203.28
|
| Rate for Payer: Ohio Health Group HMO |
$173.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$159.39
|
| Rate for Payer: PHCS Commercial |
$221.76
|
| Rate for Payer: United Healthcare All Payer |
$203.28
|
|
|
IV NCHEMO ADDTL DRUG(T
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
260T0010
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$221.76 |
| Rate for Payer: Aetna Commercial |
$177.87
|
| Rate for Payer: Anthem Medicaid |
$79.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$42.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$59.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.55
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$191.73
|
| Rate for Payer: First Health Commercial |
$219.45
|
| Rate for Payer: Humana Commercial |
$196.35
|
| Rate for Payer: Humana KY Medicaid |
$79.44
|
| Rate for Payer: Humana Medicare Advantage |
$42.63
|
| Rate for Payer: Kentucky WC Medicaid |
$80.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$189.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$170.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$81.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$203.28
|
| Rate for Payer: Ohio Health Group HMO |
$173.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$159.39
|
| Rate for Payer: PHCS Commercial |
$221.76
|
| Rate for Payer: United Healthcare All Payer |
$203.28
|
|
|
IVPYELOGRAM LIMITED
|
Facility
|
IP
|
$826.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
32000143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$247.80 |
| Max. Negotiated Rate |
$792.96 |
| Rate for Payer: Aetna Commercial |
$636.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$644.28
|
| Rate for Payer: Cash Price |
$413.00
|
| Rate for Payer: Cigna Commercial |
$685.58
|
| Rate for Payer: First Health Commercial |
$784.70
|
| Rate for Payer: Humana Commercial |
$702.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$677.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$609.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$726.88
|
| Rate for Payer: Ohio Health Group HMO |
$619.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$660.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$569.94
|
| Rate for Payer: PHCS Commercial |
$792.96
|
| Rate for Payer: United Healthcare All Payer |
$726.88
|
|
|
IVPYELOGRAM LIMITED
|
Facility
|
OP
|
$826.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
32000143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$792.96 |
| Rate for Payer: Aetna Commercial |
$636.02
|
| Rate for Payer: Anthem Medicaid |
$284.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$644.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$413.00
|
| Rate for Payer: Cash Price |
$413.00
|
| Rate for Payer: Cigna Commercial |
$685.58
|
| Rate for Payer: First Health Commercial |
$784.70
|
| Rate for Payer: Humana Commercial |
$702.10
|
| Rate for Payer: Humana KY Medicaid |
$284.06
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$286.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$677.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$609.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$289.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$726.88
|
| Rate for Payer: Ohio Health Group HMO |
$619.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$660.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$569.94
|
| Rate for Payer: PHCS Commercial |
$792.96
|
| Rate for Payer: United Healthcare All Payer |
$726.88
|
|
|
IVPYELOGRAM LIMITED
|
Professional
|
Both
|
$826.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
32000143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$31.17 |
| Max. Negotiated Rate |
$495.60 |
| Rate for Payer: Aetna Commercial |
$165.46
|
| Rate for Payer: Ambetter Exchange |
$118.56
|
| Rate for Payer: Anthem Medicaid |
$66.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$118.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$118.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$142.27
|
| Rate for Payer: Cash Price |
$413.00
|
| Rate for Payer: Cash Price |
$413.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$118.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.93
|
| Rate for Payer: Molina Healthcare Passport |
$66.60
|
| Rate for Payer: Multiplan PHCS |
$495.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.13
|
| Rate for Payer: UHCCP Medicaid |
$289.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$67.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$118.56
|
|
|
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: Ambetter Exchange |
$118.56
|
| Rate for Payer: Anthem Medicaid |
$66.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$118.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$118.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$142.27
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$118.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.56
|
| 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 |
$154.13
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$67.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$118.56
|
|
|
IVPYELOGRAM LIMITED(T
|
Facility
|
IP
|
$751.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
320T0143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$225.30 |
| Max. Negotiated Rate |
$720.96 |
| Rate for Payer: Aetna Commercial |
$578.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.78
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$623.33
|
| Rate for Payer: First Health Commercial |
$713.45
|
| Rate for Payer: Humana Commercial |
$638.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$554.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.88
|
| Rate for Payer: Ohio Health Group HMO |
$563.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$653.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$518.19
|
| Rate for Payer: PHCS Commercial |
$720.96
|
| Rate for Payer: United Healthcare All Payer |
$660.88
|
|
|
IVPYELOGRAM LIMITED(T
|
Facility
|
OP
|
$751.00
|
|
|
Service Code
|
HCPCS 74400
|
| Hospital Charge Code |
320T0143
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$720.96 |
| Rate for Payer: Aetna Commercial |
$578.27
|
| Rate for Payer: Anthem Medicaid |
$258.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$623.33
|
| Rate for Payer: First Health Commercial |
$713.45
|
| Rate for Payer: Humana Commercial |
$638.35
|
| Rate for Payer: Humana KY Medicaid |
$258.27
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$260.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$554.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.88
|
| Rate for Payer: Ohio Health Group HMO |
$563.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$653.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$518.19
|
| Rate for Payer: PHCS Commercial |
$720.96
|
| Rate for Payer: United Healthcare All Payer |
$660.88
|
|
|
IV SEQ SAME DRUG >30 MIN EA
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
26000011
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$58.20 |
| Max. Negotiated Rate |
$186.24 |
| Rate for Payer: Aetna Commercial |
$149.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$151.32
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$161.02
|
| Rate for Payer: First Health Commercial |
$184.30
|
| Rate for Payer: Humana Commercial |
$164.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$170.72
|
| Rate for Payer: Ohio Health Group HMO |
$145.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.86
|
| Rate for Payer: PHCS Commercial |
$186.24
|
| Rate for Payer: United Healthcare All Payer |
$170.72
|
|
|
IV SEQ SAME DRUG >30 MIN EA
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
26000011
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$58.20 |
| Max. Negotiated Rate |
$186.24 |
| Rate for Payer: Aetna Commercial |
$149.38
|
| Rate for Payer: Anthem Medicaid |
$66.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$151.32
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$161.02
|
| Rate for Payer: First Health Commercial |
$184.30
|
| Rate for Payer: Humana Commercial |
$164.90
|
| Rate for Payer: Humana KY Medicaid |
$66.72
|
| Rate for Payer: Kentucky WC Medicaid |
$67.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$170.72
|
| Rate for Payer: Ohio Health Group HMO |
$145.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.86
|
| Rate for Payer: PHCS Commercial |
$186.24
|
| Rate for Payer: United Healthcare All Payer |
$170.72
|
|
|
IXEMPRA 1 MG (15MG VIAL)
|
Facility
|
OP
|
$10,979.35
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$138.67 |
| Max. Negotiated Rate |
$10,540.18 |
| Rate for Payer: Aetna Commercial |
$8,454.10
|
| Rate for Payer: Anthem Medicaid |
$3,775.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$138.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,563.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$194.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.20
|
| Rate for Payer: Cash Price |
$5,489.68
|
| Rate for Payer: Cash Price |
$5,489.68
|
| Rate for Payer: Cigna Commercial |
$9,112.86
|
| Rate for Payer: First Health Commercial |
$10,430.38
|
| Rate for Payer: Humana Commercial |
$9,332.45
|
| Rate for Payer: Humana KY Medicaid |
$3,775.80
|
| Rate for Payer: Humana Medicare Advantage |
$138.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3,814.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,003.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,102.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,851.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,661.83
|
| Rate for Payer: Ohio Health Group HMO |
$8,234.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,783.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,552.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,575.75
|
| Rate for Payer: PHCS Commercial |
$10,540.18
|
| Rate for Payer: United Healthcare All Payer |
$9,661.83
|
|
|
IXEMPRA 1 MG (15MG VIAL)
|
Facility
|
IP
|
$10,979.35
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,293.80 |
| Max. Negotiated Rate |
$10,540.18 |
| Rate for Payer: Aetna Commercial |
$8,454.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,563.89
|
| Rate for Payer: Cash Price |
$5,489.68
|
| Rate for Payer: Cigna Commercial |
$9,112.86
|
| Rate for Payer: First Health Commercial |
$10,430.38
|
| Rate for Payer: Humana Commercial |
$9,332.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,003.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,102.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,293.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,661.83
|
| Rate for Payer: Ohio Health Group HMO |
$8,234.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,783.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,552.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,575.75
|
| Rate for Payer: PHCS Commercial |
$10,540.18
|
| Rate for Payer: United Healthcare All Payer |
$9,661.83
|
|
|
IXEMPRA 1MG (45MG VIAL)
|
Facility
|
IP
|
$32,938.06
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,881.42 |
| Max. Negotiated Rate |
$31,620.54 |
| Rate for Payer: Aetna Commercial |
$25,362.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,691.69
|
| Rate for Payer: Cash Price |
$16,469.03
|
| Rate for Payer: Cigna Commercial |
$27,338.59
|
| Rate for Payer: First Health Commercial |
$31,291.16
|
| Rate for Payer: Humana Commercial |
$27,997.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,009.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,308.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,881.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,985.49
|
| Rate for Payer: Ohio Health Group HMO |
$24,703.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,350.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,656.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,727.26
|
| Rate for Payer: PHCS Commercial |
$31,620.54
|
| Rate for Payer: United Healthcare All Payer |
$28,985.49
|
|
|
IXEMPRA 1MG (45MG VIAL)
|
Facility
|
OP
|
$32,938.06
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
25002628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$138.67 |
| Max. Negotiated Rate |
$31,620.54 |
| Rate for Payer: Aetna Commercial |
$25,362.31
|
| Rate for Payer: Anthem Medicaid |
$11,327.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$138.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,691.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$194.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.20
|
| Rate for Payer: Cash Price |
$16,469.03
|
| Rate for Payer: Cash Price |
$16,469.03
|
| Rate for Payer: Cigna Commercial |
$27,338.59
|
| Rate for Payer: First Health Commercial |
$31,291.16
|
| Rate for Payer: Humana Commercial |
$27,997.35
|
| Rate for Payer: Humana KY Medicaid |
$11,327.40
|
| Rate for Payer: Humana Medicare Advantage |
$138.67
|
| Rate for Payer: Kentucky WC Medicaid |
$11,442.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,009.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,308.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,554.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,985.49
|
| Rate for Payer: Ohio Health Group HMO |
$24,703.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,350.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,656.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,727.26
|
| Rate for Payer: PHCS Commercial |
$31,620.54
|
| Rate for Payer: United Healthcare All Payer |
$28,985.49
|
|
|
JACKY RADIAL 5FR
|
Facility
|
OP
|
$1,130.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem Medicaid |
$388.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Humana KY Medicaid |
$388.61
|
| Rate for Payer: Kentucky WC Medicaid |
$392.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
JACKY RADIAL 5FR
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
JAGTOME
|
Facility
|
IP
|
$3,511.25
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,053.38 |
| Max. Negotiated Rate |
$3,370.80 |
| Rate for Payer: Aetna Commercial |
$2,703.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,738.78
|
| Rate for Payer: Cash Price |
$1,755.62
|
| Rate for Payer: Cigna Commercial |
$2,914.34
|
| Rate for Payer: First Health Commercial |
$3,335.69
|
| Rate for Payer: Humana Commercial |
$2,984.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,879.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,591.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,089.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,633.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,809.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,054.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,422.76
|
| Rate for Payer: PHCS Commercial |
$3,370.80
|
| Rate for Payer: United Healthcare All Payer |
$3,089.90
|
|
|
JAGTOME
|
Facility
|
OP
|
$3,511.25
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,053.38 |
| Max. Negotiated Rate |
$3,370.80 |
| Rate for Payer: Aetna Commercial |
$2,703.66
|
| Rate for Payer: Anthem Medicaid |
$1,207.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,738.78
|
| Rate for Payer: Cash Price |
$1,755.62
|
| Rate for Payer: Cigna Commercial |
$2,914.34
|
| Rate for Payer: First Health Commercial |
$3,335.69
|
| Rate for Payer: Humana Commercial |
$2,984.56
|
| Rate for Payer: Humana KY Medicaid |
$1,207.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,219.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,879.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,591.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,231.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,089.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,633.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,809.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,054.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,422.76
|
| Rate for Payer: PHCS Commercial |
$3,370.80
|
| Rate for Payer: United Healthcare All Payer |
$3,089.90
|
|
|
JAGWIRE DISCOVER
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
