|
TEZSPIRE 210MG PFS
|
Facility
|
OP
|
$22,676.96
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,948.00 |
| Max. Negotiated Rate |
$21,769.88 |
| Rate for Payer: Aetna Commercial |
$17,461.26
|
| Rate for Payer: Anthem Medicaid |
$7,798.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,688.03
|
| Rate for Payer: Cash Price |
$11,338.48
|
| Rate for Payer: Cigna Commercial |
$18,821.88
|
| Rate for Payer: First Health Commercial |
$21,543.11
|
| Rate for Payer: Humana Commercial |
$19,275.42
|
| Rate for Payer: Humana KY Medicaid |
$7,798.61
|
| Rate for Payer: Kentucky WC Medicaid |
$7,877.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,595.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,735.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,803.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,955.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,955.72
|
| Rate for Payer: Ohio Health Group HMO |
$17,007.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,535.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,948.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,029.86
|
| Rate for Payer: PHCS Commercial |
$21,769.88
|
| Rate for Payer: United Healthcare All Payer |
$19,955.72
|
|
|
TEZSPIRE 210MG PFS
|
Facility
|
IP
|
$22,676.96
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,948.00 |
| Max. Negotiated Rate |
$21,769.88 |
| Rate for Payer: Aetna Commercial |
$17,461.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,688.03
|
| Rate for Payer: Cash Price |
$11,338.48
|
| Rate for Payer: Cigna Commercial |
$18,821.88
|
| Rate for Payer: First Health Commercial |
$21,543.11
|
| Rate for Payer: Humana Commercial |
$19,275.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,595.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,735.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,803.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,955.72
|
| Rate for Payer: Ohio Health Group HMO |
$17,007.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,535.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,948.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,029.86
|
| Rate for Payer: PHCS Commercial |
$21,769.88
|
| Rate for Payer: United Healthcare All Payer |
$19,955.72
|
|
|
THALLIUM A PER MCI
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
34000049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
THALLIUM A PER MCI
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
34000049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
THALLIUM A PER MCI
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
34000049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
THALLIUM A PER MCI(T
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
340T0049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
THALLIUM A PER MCI(T
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
340T0049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
TH CRISIS MANAGEMENT
|
Professional
|
Both
|
$772.00
|
|
|
Service Code
|
HCPCS 90839
|
| Hospital Charge Code |
90000026
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$218.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$97.31
|
| Rate for Payer: Anthem Medicaid |
$107.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$772.00
|
| Rate for Payer: Cash Price |
$386.00
|
| Rate for Payer: Cash Price |
$386.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$107.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.51
|
| Rate for Payer: Molina Healthcare Passport |
$107.36
|
| Rate for Payer: Multiplan PHCS |
$463.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$540.40
|
| Rate for Payer: UHCCP Medicaid |
$102.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.43
|
|
|
THEO-24 100 MG CAPSULE
|
Facility
|
IP
|
$11.52
|
|
|
Service Code
|
NDC 52244010010
|
| Hospital Charge Code |
25001519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$11.06 |
| Rate for Payer: Aetna Commercial |
$8.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.99
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cigna Commercial |
$9.56
|
| Rate for Payer: First Health Commercial |
$10.94
|
| Rate for Payer: Humana Commercial |
$9.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.14
|
| Rate for Payer: Ohio Health Group HMO |
$8.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.57
|
| Rate for Payer: PHCS Commercial |
$11.06
|
| Rate for Payer: United Healthcare All Payer |
$10.14
|
|
|
THEO-24 100 MG CAPSULE
|
Facility
|
OP
|
$11.52
|
|
|
Service Code
|
NDC 52244010010
|
| Hospital Charge Code |
25001519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$11.06 |
| Rate for Payer: Aetna Commercial |
$8.87
|
| Rate for Payer: Anthem Medicaid |
$3.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.99
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cigna Commercial |
$9.56
|
| Rate for Payer: First Health Commercial |
$10.94
|
| Rate for Payer: Humana Commercial |
$9.79
|
| Rate for Payer: Humana KY Medicaid |
$3.96
|
| Rate for Payer: Kentucky WC Medicaid |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.14
|
| Rate for Payer: Ohio Health Group HMO |
$8.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.57
|
| Rate for Payer: PHCS Commercial |
$11.06
|
| Rate for Payer: United Healthcare All Payer |
$10.14
|
|
|
THEO-24 (THEOPHYLLI 200MG/1CAP
|
Facility
|
OP
|
$22.23
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
25001517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Aetna Commercial |
$17.12
|
| Rate for Payer: Anthem Medicaid |
$7.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.34
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.45
|
| Rate for Payer: First Health Commercial |
$21.12
|
| Rate for Payer: Humana Commercial |
$18.90
|
| Rate for Payer: Humana KY Medicaid |
$7.64
|
| Rate for Payer: Kentucky WC Medicaid |
$7.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.56
|
| Rate for Payer: Ohio Health Group HMO |
$16.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$21.34
|
| Rate for Payer: United Healthcare All Payer |
$19.56
|
|
|
THEO-24 (THEOPHYLLI 200MG/1CAP
|
Facility
|
IP
|
$22.23
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
25001517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Aetna Commercial |
$17.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.34
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.45
|
| Rate for Payer: First Health Commercial |
$21.12
|
| Rate for Payer: Humana Commercial |
$18.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.56
|
| Rate for Payer: Ohio Health Group HMO |
$16.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$21.34
|
| Rate for Payer: United Healthcare All Payer |
$19.56
|
|
|
THEO-24 (THEOPHYLLI 300MG/1CAP
|
Facility
|
IP
|
$23.43
|
|
|
Service Code
|
NDC 52244030010
|
| Hospital Charge Code |
25001518
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$22.49 |
| Rate for Payer: Aetna Commercial |
$18.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.28
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cigna Commercial |
$19.45
|
| Rate for Payer: First Health Commercial |
$22.26
|
| Rate for Payer: Humana Commercial |
$19.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.62
|
| Rate for Payer: Ohio Health Group HMO |
$17.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.26
|
| Rate for Payer: PHCS Commercial |
$22.49
|
| Rate for Payer: United Healthcare All Payer |
$20.62
|
|
|
THEO-24 (THEOPHYLLI 300MG/1CAP
|
Facility
|
OP
|
$23.43
|
|
|
Service Code
|
NDC 52244030010
|
| Hospital Charge Code |
25001518
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$22.49 |
| Rate for Payer: Aetna Commercial |
$18.04
|
| Rate for Payer: Anthem Medicaid |
$8.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.28
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cigna Commercial |
$19.45
|
| Rate for Payer: First Health Commercial |
$22.26
|
| Rate for Payer: Humana Commercial |
$19.92
|
| Rate for Payer: Humana KY Medicaid |
$8.06
|
| Rate for Payer: Kentucky WC Medicaid |
$8.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.62
|
| Rate for Payer: Ohio Health Group HMO |
$17.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.26
|
| Rate for Payer: PHCS Commercial |
$22.49
|
| Rate for Payer: United Healthcare All Payer |
$20.62
|
|
|
THEO-DUR (THEOPHYLL 300MG/1TAB
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 68462072101
|
| Hospital Charge Code |
25001522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: First Health Commercial |
$8.84
|
| Rate for Payer: Humana Commercial |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$8.93
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
THEO-DUR (THEOPHYLL 300MG/1TAB
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 68462072101
|
| Hospital Charge Code |
25001522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Anthem Medicaid |
$3.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: First Health Commercial |
$8.84
|
| Rate for Payer: Humana Commercial |
$7.90
|
| Rate for Payer: Humana KY Medicaid |
$3.20
|
| Rate for Payer: Kentucky WC Medicaid |
$3.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$8.93
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
THEO-DUR (THEOPHYLL 450MG/1TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 62332002631
|
| Hospital Charge Code |
25001523
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
THEO-DUR (THEOPHYLL 450MG/1TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 62332002631
|
| Hospital Charge Code |
25001523
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
THEOPHYLLINE 160MG/ 160MG/30ML
|
Facility
|
IP
|
$12.73
|
|
|
Service Code
|
NDC 27808003301
|
| Hospital Charge Code |
25001524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$12.22 |
| Rate for Payer: Aetna Commercial |
$9.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.93
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cigna Commercial |
$10.57
|
| Rate for Payer: First Health Commercial |
$12.09
|
| Rate for Payer: Humana Commercial |
$10.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.20
|
| Rate for Payer: Ohio Health Group HMO |
$9.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.95
|
| Rate for Payer: PHCS Commercial |
$12.22
|
| Rate for Payer: United Healthcare All Payer |
$11.20
|
|
|
THEOPHYLLINE 160MG/ 160MG/30ML
|
Facility
|
OP
|
$12.73
|
|
|
Service Code
|
NDC 27808003301
|
| Hospital Charge Code |
25001524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$12.22 |
| Rate for Payer: Aetna Commercial |
$9.80
|
| Rate for Payer: Anthem Medicaid |
$4.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.93
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cigna Commercial |
$10.57
|
| Rate for Payer: First Health Commercial |
$12.09
|
| Rate for Payer: Humana Commercial |
$10.82
|
| Rate for Payer: Humana KY Medicaid |
$4.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.20
|
| Rate for Payer: Ohio Health Group HMO |
$9.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.95
|
| Rate for Payer: PHCS Commercial |
$12.22
|
| Rate for Payer: United Healthcare All Payer |
$11.20
|
|
|
THERAGRAN (MULTIVITAMIN) 1TAB
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
25001525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
THERAGRAN (MULTIVITAMIN) 1TAB
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
25001525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
THERAPEUTI APHERESIS RBC
|
Facility
|
OP
|
$1,896.00
|
|
|
Service Code
|
HCPCS 36512
|
| Hospital Charge Code |
76101469
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.48 |
| Max. Negotiated Rate |
$1,857.53 |
| Rate for Payer: Aetna Commercial |
$1,459.92
|
| Rate for Payer: Anthem Medicaid |
$652.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,326.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,857.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,791.19
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cigna Commercial |
$1,573.68
|
| Rate for Payer: First Health Commercial |
$1,801.20
|
| Rate for Payer: Humana Commercial |
$1,611.60
|
| Rate for Payer: Humana KY Medicaid |
$652.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,326.81
|
| Rate for Payer: Kentucky WC Medicaid |
$658.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,399.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,592.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$665.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,668.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,422.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.76
|
| Rate for Payer: PHCS Commercial |
$1,820.16
|
| Rate for Payer: United Healthcare All Payer |
$1,668.48
|
|
|
THERAPEUTI APHERESIS RBC
|
Facility
|
IP
|
$1,896.00
|
|
|
Service Code
|
HCPCS 36512
|
| Hospital Charge Code |
76101469
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.48 |
| Max. Negotiated Rate |
$1,820.16 |
| Rate for Payer: Aetna Commercial |
$1,459.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.88
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cigna Commercial |
$1,573.68
|
| Rate for Payer: First Health Commercial |
$1,801.20
|
| Rate for Payer: Humana Commercial |
$1,611.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,399.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,668.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,422.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.76
|
| Rate for Payer: PHCS Commercial |
$1,820.16
|
| Rate for Payer: United Healthcare All Payer |
$1,668.48
|
|
|
THERAPEUTIC ACTIV-15 MIN
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 97530
|
| Hospital Charge Code |
43000023
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$123.84 |
| Rate for Payer: Aetna Commercial |
$99.33
|
| Rate for Payer: Anthem Medicaid |
$44.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.62
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$107.07
|
| Rate for Payer: First Health Commercial |
$122.55
|
| Rate for Payer: Humana Commercial |
$109.65
|
| Rate for Payer: Humana KY Medicaid |
$44.36
|
| Rate for Payer: Kentucky WC Medicaid |
$44.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.52
|
| Rate for Payer: Ohio Health Group HMO |
$96.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.99
|
| Rate for Payer: PHCS Commercial |
$123.84
|
| Rate for Payer: United Healthcare All Payer |
$113.52
|
|
