|
MYELOGRAPHY NECK SPINE
|
Facility
|
IP
|
$2,213.00
|
|
|
Service Code
|
HCPCS 72240
|
| Hospital Charge Code |
32000271
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$287.69 |
| Max. Negotiated Rate |
$2,124.48 |
| Rate for Payer: Aetna Commercial |
$1,704.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,726.14
|
| Rate for Payer: Cash Price |
$1,106.50
|
| Rate for Payer: Cigna Commercial |
$1,836.79
|
| Rate for Payer: First Health Commercial |
$2,102.35
|
| Rate for Payer: Humana Commercial |
$1,881.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,814.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,633.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,947.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,659.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$442.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$686.03
|
| Rate for Payer: PHCS Commercial |
$2,124.48
|
| Rate for Payer: United Healthcare All Payer |
$1,947.44
|
|
|
MYELOGRAPHY NECK SPINE
|
Facility
|
OP
|
$2,213.00
|
|
|
Service Code
|
HCPCS 72240
|
| Hospital Charge Code |
32000271
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$287.69 |
| Max. Negotiated Rate |
$2,124.48 |
| Rate for Payer: Aetna Commercial |
$1,704.01
|
| Rate for Payer: Anthem Medicaid |
$761.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$692.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,726.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$969.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$934.73
|
| Rate for Payer: Cash Price |
$1,106.50
|
| Rate for Payer: Cash Price |
$1,106.50
|
| Rate for Payer: Cigna Commercial |
$1,836.79
|
| Rate for Payer: First Health Commercial |
$2,102.35
|
| Rate for Payer: Humana Commercial |
$1,881.05
|
| Rate for Payer: Humana KY Medicaid |
$761.05
|
| Rate for Payer: Humana Medicare Advantage |
$692.39
|
| Rate for Payer: Kentucky WC Medicaid |
$768.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,814.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,633.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$830.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$776.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,947.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,659.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$442.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$686.03
|
| Rate for Payer: PHCS Commercial |
$2,124.48
|
| Rate for Payer: United Healthcare All Payer |
$1,947.44
|
|
|
MYELOGRAPHY NECK SPINE(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 72240
|
| Hospital Charge Code |
320P0271
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$305.82 |
| Rate for Payer: Aetna Commercial |
$243.90
|
| Rate for Payer: Anthem Medicaid |
$167.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$305.82
|
| Rate for Payer: Healthspan PPO |
$228.54
|
| Rate for Payer: Humana Medicaid |
$167.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$170.79
|
| Rate for Payer: Molina Healthcare Passport |
$167.44
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$169.11
|
|
|
MYELOGRAPHY NECK SPINE(T
|
Facility
|
OP
|
$2,088.00
|
|
|
Service Code
|
HCPCS 72240
|
| Hospital Charge Code |
320T0271
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$271.44 |
| Max. Negotiated Rate |
$2,004.48 |
| Rate for Payer: Aetna Commercial |
$1,607.76
|
| Rate for Payer: Anthem Medicaid |
$718.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$692.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,628.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$969.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$934.73
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cigna Commercial |
$1,733.04
|
| Rate for Payer: First Health Commercial |
$1,983.60
|
| Rate for Payer: Humana Commercial |
$1,774.80
|
| Rate for Payer: Humana KY Medicaid |
$718.06
|
| Rate for Payer: Humana Medicare Advantage |
$692.39
|
| Rate for Payer: Kentucky WC Medicaid |
$725.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,712.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,540.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$830.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$732.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,837.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$647.28
|
| Rate for Payer: PHCS Commercial |
$2,004.48
|
| Rate for Payer: United Healthcare All Payer |
$1,837.44
|
|
|
MYELOGRAPHY NECK SPINE(T
|
Facility
|
IP
|
$2,088.00
|
|
|
Service Code
|
HCPCS 72240
|
| Hospital Charge Code |
320T0271
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$271.44 |
| Max. Negotiated Rate |
$2,004.48 |
| Rate for Payer: Aetna Commercial |
$1,607.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,628.64
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cigna Commercial |
$1,733.04
|
| Rate for Payer: First Health Commercial |
$1,983.60
|
| Rate for Payer: Humana Commercial |
$1,774.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,712.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,540.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$626.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,837.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$647.28
|
| Rate for Payer: PHCS Commercial |
$2,004.48
|
| Rate for Payer: United Healthcare All Payer |
$1,837.44
|
|
|
MYELOGRAPHY THORACIC SPINE
|
Professional
|
Both
|
$2,431.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
32000272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.01 |
| Max. Negotiated Rate |
$2,431.00 |
| Rate for Payer: Aetna Commercial |
$223.04
|
| Rate for Payer: Anthem Medicaid |
$156.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,431.00
|
| Rate for Payer: Cash Price |
$1,215.50
|
| Rate for Payer: Cash Price |
$1,215.50
|
| Rate for Payer: Cigna Commercial |
$282.61
|
| Rate for Payer: Healthspan PPO |
$209.00
|
| Rate for Payer: Humana Medicaid |
$156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.38
|
| Rate for Payer: Molina Healthcare Passport |
$156.25
|
| Rate for Payer: Multiplan PHCS |
$1,458.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,701.70
|
| Rate for Payer: UHCCP Medicaid |
$850.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.81
|
|
|
MYELOGRAPHY THORACIC SPINE
|
Facility
|
IP
|
$2,431.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
32000272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$316.03 |
| Max. Negotiated Rate |
$2,333.76 |
| Rate for Payer: Aetna Commercial |
$1,871.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,896.18
|
| Rate for Payer: Cash Price |
$1,215.50
|
| Rate for Payer: Cigna Commercial |
$2,017.73
|
| Rate for Payer: First Health Commercial |
$2,309.45
|
| Rate for Payer: Humana Commercial |
$2,066.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,993.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,794.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$729.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,139.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,823.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$486.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$753.61
|
| Rate for Payer: PHCS Commercial |
$2,333.76
|
| Rate for Payer: United Healthcare All Payer |
$2,139.28
|
|
|
MYELOGRAPHY THORACIC SPINE
|
Facility
|
OP
|
$2,431.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
32000272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$316.03 |
| Max. Negotiated Rate |
$2,333.76 |
| Rate for Payer: Aetna Commercial |
$1,871.87
|
| Rate for Payer: Anthem Medicaid |
$836.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$692.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,896.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$969.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$934.73
|
| Rate for Payer: Cash Price |
$1,215.50
|
| Rate for Payer: Cash Price |
$1,215.50
|
| Rate for Payer: Cigna Commercial |
$2,017.73
|
| Rate for Payer: First Health Commercial |
$2,309.45
|
| Rate for Payer: Humana Commercial |
$2,066.35
|
| Rate for Payer: Humana KY Medicaid |
$836.02
|
| Rate for Payer: Humana Medicare Advantage |
$692.39
|
| Rate for Payer: Kentucky WC Medicaid |
$844.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,993.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,794.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$830.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$852.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,139.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,823.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$486.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$753.61
|
| Rate for Payer: PHCS Commercial |
$2,333.76
|
| Rate for Payer: United Healthcare All Payer |
$2,139.28
|
|
|
MYELOGRAPHY THORACIC SPINE(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
320P0272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$282.61 |
| Rate for Payer: Aetna Commercial |
$223.04
|
| Rate for Payer: Anthem Medicaid |
$156.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$282.61
|
| Rate for Payer: Healthspan PPO |
$209.00
|
| Rate for Payer: Humana Medicaid |
$156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.38
|
| Rate for Payer: Molina Healthcare Passport |
$156.25
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.81
|
|
|
MYELOGRAPHY THORACIC SPINE(T
|
Facility
|
OP
|
$2,311.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
320T0272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$300.43 |
| Max. Negotiated Rate |
$2,218.56 |
| Rate for Payer: Aetna Commercial |
$1,779.47
|
| Rate for Payer: Anthem Medicaid |
$794.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$692.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,802.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$969.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$934.73
|
| Rate for Payer: Cash Price |
$1,155.50
|
| Rate for Payer: Cash Price |
$1,155.50
|
| Rate for Payer: Cigna Commercial |
$1,918.13
|
| Rate for Payer: First Health Commercial |
$2,195.45
|
| Rate for Payer: Humana Commercial |
$1,964.35
|
| Rate for Payer: Humana KY Medicaid |
$794.75
|
| Rate for Payer: Humana Medicare Advantage |
$692.39
|
| Rate for Payer: Kentucky WC Medicaid |
$802.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,895.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,705.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$830.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$810.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,033.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,733.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$300.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$716.41
|
| Rate for Payer: PHCS Commercial |
$2,218.56
|
| Rate for Payer: United Healthcare All Payer |
$2,033.68
|
|
|
MYELOGRAPHY THORACIC SPINE(T
|
Facility
|
IP
|
$2,311.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
320T0272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$300.43 |
| Max. Negotiated Rate |
$2,218.56 |
| Rate for Payer: Aetna Commercial |
$1,779.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,802.58
|
| Rate for Payer: Cash Price |
$1,155.50
|
| Rate for Payer: Cigna Commercial |
$1,918.13
|
| Rate for Payer: First Health Commercial |
$2,195.45
|
| Rate for Payer: Humana Commercial |
$1,964.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,895.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,705.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$693.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,033.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,733.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$300.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$716.41
|
| Rate for Payer: PHCS Commercial |
$2,218.56
|
| Rate for Payer: United Healthcare All Payer |
$2,033.68
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$27,107.07
|
|
|
Service Code
|
MSDRG 827
|
| Min. Negotiated Rate |
$18,394.08 |
| Max. Negotiated Rate |
$27,107.07 |
| Rate for Payer: Anthem Medicaid |
$18,394.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$19,362.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$27,107.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$26,138.96
|
| Rate for Payer: Humana KY Medicaid |
$18,394.08
|
| Rate for Payer: Humana Medicare Advantage |
$19,362.19
|
| Rate for Payer: Kentucky WC Medicaid |
$18,578.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,234.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,761.96
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$54,135.77
|
|
|
Service Code
|
MSDRG 826
|
| Min. Negotiated Rate |
$36,734.99 |
| Max. Negotiated Rate |
$54,135.77 |
| Rate for Payer: Anthem Medicaid |
$36,734.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$38,668.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$54,135.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$52,202.35
|
| Rate for Payer: Humana KY Medicaid |
$36,734.99
|
| Rate for Payer: Humana Medicare Advantage |
$38,668.41
|
| Rate for Payer: Kentucky WC Medicaid |
$37,102.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46,402.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$37,469.69
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,189.73
|
|
|
Service Code
|
MSDRG 828
|
| Min. Negotiated Rate |
$13,021.60 |
| Max. Negotiated Rate |
$19,189.73 |
| Rate for Payer: Anthem Medicaid |
$13,021.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,706.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,189.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,504.38
|
| Rate for Payer: Humana KY Medicaid |
$13,021.60
|
| Rate for Payer: Humana Medicare Advantage |
$13,706.95
|
| Rate for Payer: Kentucky WC Medicaid |
$13,151.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,448.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,282.03
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$36,893.81
|
|
|
Service Code
|
MSDRG 829
|
| Min. Negotiated Rate |
$25,035.08 |
| Max. Negotiated Rate |
$36,893.81 |
| Rate for Payer: Anthem Medicaid |
$25,035.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$26,352.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36,893.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$35,576.17
|
| Rate for Payer: Humana KY Medicaid |
$25,035.08
|
| Rate for Payer: Humana Medicare Advantage |
$26,352.72
|
| Rate for Payer: Kentucky WC Medicaid |
$25,285.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31,623.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,535.79
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$18,497.19
|
|
|
Service Code
|
MSDRG 830
|
| Min. Negotiated Rate |
$12,551.67 |
| Max. Negotiated Rate |
$18,497.19 |
| Rate for Payer: Anthem Medicaid |
$12,551.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,212.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18,497.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$17,836.58
|
| Rate for Payer: Humana KY Medicaid |
$12,551.67
|
| Rate for Payer: Humana Medicare Advantage |
$13,212.28
|
| Rate for Payer: Kentucky WC Medicaid |
$12,677.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,854.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,802.70
|
|
|
MYFORTIC 180MG [360MG TAB DR]
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
MYFORTIC 180MG [360MG TAB DR]
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
|
|
MYFORTIC 180MG TABLET DR
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$11.57 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Anthem Medicaid |
$4.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.40
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna Commercial |
$10.00
|
| Rate for Payer: First Health Commercial |
$11.45
|
| Rate for Payer: Humana Commercial |
$10.24
|
| Rate for Payer: Humana KY Medicaid |
$4.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.60
|
| Rate for Payer: Ohio Health Group HMO |
$9.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.74
|
| Rate for Payer: PHCS Commercial |
$11.57
|
| Rate for Payer: United Healthcare All Payer |
$10.60
|
|
|
MYFORTIC 180MG TABLET DR
|
Facility
|
IP
|
$12.05
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$11.57 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.40
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna Commercial |
$10.00
|
| Rate for Payer: First Health Commercial |
$11.45
|
| Rate for Payer: Humana Commercial |
$10.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.60
|
| Rate for Payer: Ohio Health Group HMO |
$9.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.74
|
| Rate for Payer: PHCS Commercial |
$11.57
|
| Rate for Payer: United Healthcare All Payer |
$10.60
|
|
|
MYHERO PROBIOTIC REPLENISH LOT
|
Professional
|
Both
|
$115.00
|
|
| Hospital Charge Code |
22200119
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$40.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$115.00
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Multiplan PHCS |
$69.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.50
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
|
|
MYLANTA GAS(SIMETH)8 80MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
25001031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
MYLANTA GAS(SIMETH)8 80MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
25001031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
MYLOTARG (GEMTUZUMAB) 5MG VIAL
|
Facility
|
IP
|
$53,936.25
|
|
|
Service Code
|
HCPCS J9203
|
| Hospital Charge Code |
25003694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,011.71 |
| Max. Negotiated Rate |
$51,778.80 |
| Rate for Payer: Aetna Commercial |
$41,530.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42,070.28
|
| Rate for Payer: Cash Price |
$26,968.12
|
| Rate for Payer: Cigna Commercial |
$44,767.09
|
| Rate for Payer: First Health Commercial |
$51,239.44
|
| Rate for Payer: Humana Commercial |
$45,845.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44,227.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39,804.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,180.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$47,463.90
|
| Rate for Payer: Ohio Health Group HMO |
$40,452.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,787.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,720.24
|
| Rate for Payer: PHCS Commercial |
$51,778.80
|
| Rate for Payer: United Healthcare All Payer |
$47,463.90
|
|
|
MYLOTARG (GEMTUZUMAB) 5MG VIAL
|
Facility
|
OP
|
$53,936.25
|
|
|
Service Code
|
HCPCS J9203
|
| Hospital Charge Code |
25003694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.28 |
| Max. Negotiated Rate |
$51,778.80 |
| Rate for Payer: Aetna Commercial |
$41,530.91
|
| Rate for Payer: Anthem Medicaid |
$18,548.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$226.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42,070.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$316.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$305.48
|
| Rate for Payer: Cash Price |
$26,968.12
|
| Rate for Payer: Cash Price |
$26,968.12
|
| Rate for Payer: Cigna Commercial |
$44,767.09
|
| Rate for Payer: First Health Commercial |
$51,239.44
|
| Rate for Payer: Humana Commercial |
$45,845.81
|
| Rate for Payer: Humana KY Medicaid |
$18,548.68
|
| Rate for Payer: Humana Medicare Advantage |
$226.28
|
| Rate for Payer: Kentucky WC Medicaid |
$18,737.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44,227.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39,804.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,920.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$47,463.90
|
| Rate for Payer: Ohio Health Group HMO |
$40,452.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,787.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,720.24
|
| Rate for Payer: PHCS Commercial |
$51,778.80
|
| Rate for Payer: United Healthcare All Payer |
$47,463.90
|
|
