|
RESUR PAT GEN 11 7.5MM 29MM
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem Medicaid |
$1,117.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Humana KY Medicaid |
$1,117.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,129.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,140.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RESUR PAT GEN 11 7.5MM 29MM
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RESUR PAT GEN 11 7.5MM 32MM
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem Medicaid |
$1,117.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Humana KY Medicaid |
$1,117.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,129.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,140.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RESUR PAT GEN 11 7.5MM 32MM
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RESUR PAT GEN 11 7.5MM 35MM
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RESUR PAT GEN 11 7.5MM 35MM
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem Medicaid |
$1,117.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Humana KY Medicaid |
$1,117.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,129.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,140.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RETACRIT 10000 UNIT/ML VIAL
|
Facility
|
IP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.15 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.35
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 10000 UNIT/ML VIAL
|
Facility
|
OP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem Medicaid |
$206.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Humana KY Medicaid |
$206.73
|
| Rate for Payer: Humana Medicare Advantage |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$208.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.35
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 1,000u (20,000u MDV)
|
Facility
|
OP
|
$60.11
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25004158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem Medicaid |
$20.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cigna Commercial |
$49.89
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Humana KY Medicaid |
$20.67
|
| Rate for Payer: Humana Medicare Advantage |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$20.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.90
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.63
|
| Rate for Payer: PHCS Commercial |
$57.71
|
| Rate for Payer: United Healthcare All Payer |
$52.90
|
|
|
RETACRIT 1,000u (20,000u MDV)
|
Facility
|
IP
|
$60.11
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25004158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.89
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cigna Commercial |
$49.89
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.90
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.63
|
| Rate for Payer: PHCS Commercial |
$57.71
|
| Rate for Payer: United Healthcare All Payer |
$52.90
|
|
|
RETACRIT 100U (10KSDV)(ONHD)
|
Facility
|
OP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004495
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem Medicaid |
$206.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Humana KY Medicaid |
$206.73
|
| Rate for Payer: Humana Medicare Advantage |
$0.78
|
| Rate for Payer: Kentucky WC Medicaid |
$208.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.35
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 100U (10KSDV)(ONHD)
|
Facility
|
IP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004495
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$78.15 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.35
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 100U (20KMDV)(ONHD)
|
Facility
|
IP
|
$1,202.27
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004496
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$156.30 |
| Max. Negotiated Rate |
$1,154.18 |
| Rate for Payer: Aetna Commercial |
$925.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$937.77
|
| Rate for Payer: Cash Price |
$601.14
|
| Rate for Payer: Cigna Commercial |
$997.88
|
| Rate for Payer: First Health Commercial |
$1,142.16
|
| Rate for Payer: Humana Commercial |
$1,021.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$985.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$887.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,058.00
|
| Rate for Payer: Ohio Health Group HMO |
$901.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.70
|
| Rate for Payer: PHCS Commercial |
$1,154.18
|
| Rate for Payer: United Healthcare All Payer |
$1,058.00
|
|
|
RETACRIT 100U (20KMDV)(ONHD)
|
Facility
|
OP
|
$1,202.27
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004496
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1,154.18 |
| Rate for Payer: Aetna Commercial |
$925.75
|
| Rate for Payer: Anthem Medicaid |
$413.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$937.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$601.14
|
| Rate for Payer: Cash Price |
$601.14
|
| Rate for Payer: Cigna Commercial |
$997.88
|
| Rate for Payer: First Health Commercial |
$1,142.16
|
| Rate for Payer: Humana Commercial |
$1,021.93
|
| Rate for Payer: Humana KY Medicaid |
$413.46
|
| Rate for Payer: Humana Medicare Advantage |
$0.78
|
| Rate for Payer: Kentucky WC Medicaid |
$417.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$985.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$887.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$421.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,058.00
|
| Rate for Payer: Ohio Health Group HMO |
$901.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.70
|
| Rate for Payer: PHCS Commercial |
$1,154.18
|
| Rate for Payer: United Healthcare All Payer |
$1,058.00
|
|
|
RETACRIT 100U (2K SDV)(ONHD)
|
Facility
|
IP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004497
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.27
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 100U (2K SDV)(ONHD)
|
Facility
|
OP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004497
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem Medicaid |
$41.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Humana KY Medicaid |
$41.35
|
| Rate for Payer: Humana Medicare Advantage |
$0.78
|
| Rate for Payer: Kentucky WC Medicaid |
$41.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.27
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 100U(3KSDV)(ONHD)
|
Facility
|
OP
|
$180.34
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004498
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$173.13 |
| Rate for Payer: Aetna Commercial |
$138.86
|
| Rate for Payer: Anthem Medicaid |
$62.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cigna Commercial |
$149.68
|
| Rate for Payer: First Health Commercial |
$171.32
|
| Rate for Payer: Humana Commercial |
$153.29
|
| Rate for Payer: Humana KY Medicaid |
$62.02
|
| Rate for Payer: Humana Medicare Advantage |
$0.78
|
| Rate for Payer: Kentucky WC Medicaid |
$62.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.70
|
| Rate for Payer: Ohio Health Group HMO |
$135.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.91
|
| Rate for Payer: PHCS Commercial |
$173.13
|
| Rate for Payer: United Healthcare All Payer |
$158.70
|
|
|
RETACRIT 100U(3KSDV)(ONHD)
|
Facility
|
IP
|
$180.34
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004498
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$173.13 |
| Rate for Payer: Aetna Commercial |
$138.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.67
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cigna Commercial |
$149.68
|
| Rate for Payer: First Health Commercial |
$171.32
|
| Rate for Payer: Humana Commercial |
$153.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.70
|
| Rate for Payer: Ohio Health Group HMO |
$135.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.91
|
| Rate for Payer: PHCS Commercial |
$173.13
|
| Rate for Payer: United Healthcare All Payer |
$158.70
|
|
|
RETACRIT 2000 UNIT/ML VL
|
Facility
|
IP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.27
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 2000 UNIT/ML VL
|
Facility
|
OP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem Medicaid |
$41.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Humana KY Medicaid |
$41.35
|
| Rate for Payer: Humana Medicare Advantage |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$41.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.27
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 3000 UNIT/ML VL
|
Facility
|
IP
|
$180.34
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002730
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$173.13 |
| Rate for Payer: Aetna Commercial |
$138.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.67
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cigna Commercial |
$149.68
|
| Rate for Payer: First Health Commercial |
$171.32
|
| Rate for Payer: Humana Commercial |
$153.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.70
|
| Rate for Payer: Ohio Health Group HMO |
$135.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.91
|
| Rate for Payer: PHCS Commercial |
$173.13
|
| Rate for Payer: United Healthcare All Payer |
$158.70
|
|
|
RETACRIT 3000 UNIT/ML VL
|
Facility
|
OP
|
$180.34
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002730
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$173.13 |
| Rate for Payer: Aetna Commercial |
$138.86
|
| Rate for Payer: Anthem Medicaid |
$62.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cigna Commercial |
$149.68
|
| Rate for Payer: First Health Commercial |
$171.32
|
| Rate for Payer: Humana Commercial |
$153.29
|
| Rate for Payer: Humana KY Medicaid |
$62.02
|
| Rate for Payer: Humana Medicare Advantage |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$62.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.70
|
| Rate for Payer: Ohio Health Group HMO |
$135.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.91
|
| Rate for Payer: PHCS Commercial |
$173.13
|
| Rate for Payer: United Healthcare All Payer |
$158.70
|
|
|
RETACRIT 40000 UNIT/ML VIAL
|
Facility
|
OP
|
$2,404.54
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$2,308.36 |
| Rate for Payer: Aetna Commercial |
$1,851.50
|
| Rate for Payer: Anthem Medicaid |
$826.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,875.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$1,202.27
|
| Rate for Payer: Cash Price |
$1,202.27
|
| Rate for Payer: Cigna Commercial |
$1,995.77
|
| Rate for Payer: First Health Commercial |
$2,284.31
|
| Rate for Payer: Humana Commercial |
$2,043.86
|
| Rate for Payer: Humana KY Medicaid |
$826.92
|
| Rate for Payer: Humana Medicare Advantage |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$835.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,971.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,774.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$843.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,116.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,803.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$312.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$745.41
|
| Rate for Payer: PHCS Commercial |
$2,308.36
|
| Rate for Payer: United Healthcare All Payer |
$2,116.00
|
|
|
RETACRIT 40000 UNIT/ML VIAL
|
Facility
|
IP
|
$2,404.54
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$312.59 |
| Max. Negotiated Rate |
$2,308.36 |
| Rate for Payer: Aetna Commercial |
$1,851.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,875.54
|
| Rate for Payer: Cash Price |
$1,202.27
|
| Rate for Payer: Cigna Commercial |
$1,995.77
|
| Rate for Payer: First Health Commercial |
$2,284.31
|
| Rate for Payer: Humana Commercial |
$2,043.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,971.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,774.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$721.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,116.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,803.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$312.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$745.41
|
| Rate for Payer: PHCS Commercial |
$2,308.36
|
| Rate for Payer: United Healthcare All Payer |
$2,116.00
|
|
|
RETACRIT 4000 UNIT/ML VL
|
Facility
|
OP
|
$240.45
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$230.83 |
| Rate for Payer: Aetna Commercial |
$185.15
|
| Rate for Payer: Anthem Medicaid |
$82.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$187.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$120.22
|
| Rate for Payer: Cash Price |
$120.22
|
| Rate for Payer: Cigna Commercial |
$199.57
|
| Rate for Payer: First Health Commercial |
$228.43
|
| Rate for Payer: Humana Commercial |
$204.38
|
| Rate for Payer: Humana KY Medicaid |
$82.69
|
| Rate for Payer: Humana Medicare Advantage |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$83.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$197.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.60
|
| Rate for Payer: Ohio Health Group HMO |
$180.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.54
|
| Rate for Payer: PHCS Commercial |
$230.83
|
| Rate for Payer: United Healthcare All Payer |
$211.60
|
|
