|
WARFARIN 2 MG TABLET
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 62584098401
|
| Hospital Charge Code |
25000485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
WARFARIN 2 MG TABLET
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 62584098401
|
| Hospital Charge Code |
25000485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
WARFARIN 3.75mg(1/2of7.5mg)Tab
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
WARFARIN 3.75mg(1/2of7.5mg)Tab
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
WARFARIN 3 MG TABLET
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000487
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
WARFARIN 3 MG TABLET
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000487
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
WARFARIN 4 MG TABLET
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
WARFARIN 4 MG TABLET
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
WARFARIN 5 MG TABLET
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
WARFARIN 5 MG TABLET
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
WARFARIN 6 MG TABLET
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000490
|
|
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
|
|
|
WARFARIN 6 MG TABLET
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000490
|
|
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
|
|
|
WARFARIN 7.5 MG TABLET
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
WARFARIN 7.5 MG TABLET
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
WARFARIN TABLETS FEE.QMONTH
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 832121801
|
| Hospital Charge Code |
25003991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
WARFARIN TABLETS FEE.QMONTH
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 832121801
|
| Hospital Charge Code |
25003991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Humana KY Medicaid |
$3.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
|
|
WASHER 1MM BLACK
|
Facility
|
OP
|
$809.92
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.29 |
| Max. Negotiated Rate |
$777.52 |
| Rate for Payer: Aetna Commercial |
$623.64
|
| Rate for Payer: Anthem Medicaid |
$278.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.74
|
| Rate for Payer: Cash Price |
$404.96
|
| Rate for Payer: Cigna Commercial |
$672.23
|
| Rate for Payer: First Health Commercial |
$769.42
|
| Rate for Payer: Humana Commercial |
$688.43
|
| Rate for Payer: Humana KY Medicaid |
$278.53
|
| Rate for Payer: Kentucky WC Medicaid |
$281.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$242.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.73
|
| Rate for Payer: Ohio Health Group HMO |
$607.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$161.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.08
|
| Rate for Payer: PHCS Commercial |
$777.52
|
| Rate for Payer: United Healthcare All Payer |
$712.73
|
|
|
WASHER 1MM BLACK
|
Facility
|
IP
|
$809.92
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.29 |
| Max. Negotiated Rate |
$777.52 |
| Rate for Payer: Aetna Commercial |
$623.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.74
|
| Rate for Payer: Cash Price |
$404.96
|
| Rate for Payer: Cigna Commercial |
$672.23
|
| Rate for Payer: First Health Commercial |
$769.42
|
| Rate for Payer: Humana Commercial |
$688.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$242.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.73
|
| Rate for Payer: Ohio Health Group HMO |
$607.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$161.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.08
|
| Rate for Payer: PHCS Commercial |
$777.52
|
| Rate for Payer: United Healthcare All Payer |
$712.73
|
|
|
WASHER 7MM RED
|
Facility
|
IP
|
$809.92
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.29 |
| Max. Negotiated Rate |
$777.52 |
| Rate for Payer: Aetna Commercial |
$623.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.74
|
| Rate for Payer: Cash Price |
$404.96
|
| Rate for Payer: Cigna Commercial |
$672.23
|
| Rate for Payer: First Health Commercial |
$769.42
|
| Rate for Payer: Humana Commercial |
$688.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$242.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.73
|
| Rate for Payer: Ohio Health Group HMO |
$607.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$161.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.08
|
| Rate for Payer: PHCS Commercial |
$777.52
|
| Rate for Payer: United Healthcare All Payer |
$712.73
|
|
|
WASHER 7MM RED
|
Facility
|
OP
|
$809.92
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.29 |
| Max. Negotiated Rate |
$777.52 |
| Rate for Payer: Aetna Commercial |
$623.64
|
| Rate for Payer: Anthem Medicaid |
$278.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.74
|
| Rate for Payer: Cash Price |
$404.96
|
| Rate for Payer: Cigna Commercial |
$672.23
|
| Rate for Payer: First Health Commercial |
$769.42
|
| Rate for Payer: Humana Commercial |
$688.43
|
| Rate for Payer: Humana KY Medicaid |
$278.53
|
| Rate for Payer: Kentucky WC Medicaid |
$281.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$242.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.73
|
| Rate for Payer: Ohio Health Group HMO |
$607.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$161.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.08
|
| Rate for Payer: PHCS Commercial |
$777.52
|
| Rate for Payer: United Healthcare All Payer |
$712.73
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
OP
|
$11.52
|
|
| Hospital Charge Code |
636T0101
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
IP
|
$11.52
|
|
| Hospital Charge Code |
63600101
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
OP
|
$11.52
|
|
| Hospital Charge Code |
63600101
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Professional
|
Both
|
$11.52
|
|
| Hospital Charge Code |
63600101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: Buckeye Medicare Advantage |
$11.52
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Multiplan PHCS |
$6.91
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8.06
|
| Rate for Payer: UHCCP Medicaid |
$4.03
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
IP
|
$80.39
|
|
|
Service Code
|
NDC 409488717
|
| Hospital Charge Code |
25003594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.70
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.72
|
| Rate for Payer: First Health Commercial |
$76.37
|
| Rate for Payer: Humana Commercial |
$68.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.74
|
| Rate for Payer: Ohio Health Group HMO |
$60.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.92
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
