|
WARFARIN 4 MG TABLET
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25000488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| 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 |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| 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 |
$1.31 |
| 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 |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| 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 |
$1.31 |
| 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 |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| 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 |
$1.33 |
| 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 |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.33 |
| 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 |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.33 |
| 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 |
$1.33
|
| 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 |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| 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 |
$1.33 |
| 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 |
$1.33
|
| 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 |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| 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 |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| 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 |
$2.85 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
WASHER 1MM BLACK
|
Facility
|
IP
|
$833.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$249.97 |
| Max. Negotiated Rate |
$799.92 |
| Rate for Payer: Aetna Commercial |
$641.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$649.93
|
| Rate for Payer: Cash Price |
$416.62
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: First Health Commercial |
$791.59
|
| Rate for Payer: Humana Commercial |
$708.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$614.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$249.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.26
|
| Rate for Payer: Ohio Health Group HMO |
$624.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$666.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$574.94
|
| Rate for Payer: PHCS Commercial |
$799.92
|
| Rate for Payer: United Healthcare All Payer |
$733.26
|
|
|
WASHER 1MM BLACK
|
Facility
|
OP
|
$833.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$249.97 |
| Max. Negotiated Rate |
$799.92 |
| Rate for Payer: Aetna Commercial |
$641.60
|
| Rate for Payer: Anthem Medicaid |
$286.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$649.93
|
| Rate for Payer: Cash Price |
$416.62
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: First Health Commercial |
$791.59
|
| Rate for Payer: Humana Commercial |
$708.26
|
| Rate for Payer: Humana KY Medicaid |
$286.55
|
| Rate for Payer: Kentucky WC Medicaid |
$289.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$614.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$249.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$292.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.26
|
| Rate for Payer: Ohio Health Group HMO |
$624.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$666.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$574.94
|
| Rate for Payer: PHCS Commercial |
$799.92
|
| Rate for Payer: United Healthcare All Payer |
$733.26
|
|
|
WASHER 4.0
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
WASHER 4.0
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
WASHER 7MM RED
|
Facility
|
OP
|
$833.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$249.97 |
| Max. Negotiated Rate |
$799.92 |
| Rate for Payer: Aetna Commercial |
$641.60
|
| Rate for Payer: Anthem Medicaid |
$286.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$649.93
|
| Rate for Payer: Cash Price |
$416.62
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: First Health Commercial |
$791.59
|
| Rate for Payer: Humana Commercial |
$708.26
|
| Rate for Payer: Humana KY Medicaid |
$286.55
|
| Rate for Payer: Kentucky WC Medicaid |
$289.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$614.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$249.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$292.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.26
|
| Rate for Payer: Ohio Health Group HMO |
$624.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$666.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$574.94
|
| Rate for Payer: PHCS Commercial |
$799.92
|
| Rate for Payer: United Healthcare All Payer |
$733.26
|
|
|
WASHER 7MM RED
|
Facility
|
IP
|
$833.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$249.97 |
| Max. Negotiated Rate |
$799.92 |
| Rate for Payer: Aetna Commercial |
$641.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$649.93
|
| Rate for Payer: Cash Price |
$416.62
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: First Health Commercial |
$791.59
|
| Rate for Payer: Humana Commercial |
$708.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$614.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$249.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.26
|
| Rate for Payer: Ohio Health Group HMO |
$624.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$666.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$574.94
|
| Rate for Payer: PHCS Commercial |
$799.92
|
| Rate for Payer: United Healthcare All Payer |
$733.26
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
IP
|
$80.39
|
|
| Hospital Charge Code |
636T0101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| 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 |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
OP
|
$80.39
|
|
| Hospital Charge Code |
636T0101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem Medicaid |
$27.65
|
| 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: Humana KY Medicaid |
$27.65
|
| Rate for Payer: Kentucky WC Medicaid |
$27.93
|
| 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: Molina Healthcare Medicaid |
$28.20
|
| 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 |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
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 |
$24.12 |
| 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 |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
IP
|
$80.39
|
|
| Hospital Charge Code |
63600101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| 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 |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
OP
|
$80.39
|
|
|
Service Code
|
NDC 409488717
|
| Hospital Charge Code |
25003594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem Medicaid |
$27.65
|
| 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: Humana KY Medicaid |
$27.65
|
| Rate for Payer: Kentucky WC Medicaid |
$27.93
|
| 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: Molina Healthcare Medicaid |
$28.20
|
| 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 |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Facility
|
OP
|
$80.39
|
|
| Hospital Charge Code |
63600101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem Medicaid |
$27.65
|
| 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: Humana KY Medicaid |
$27.65
|
| Rate for Payer: Kentucky WC Medicaid |
$27.93
|
| 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: Molina Healthcare Medicaid |
$28.20
|
| 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 |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
WATER FOR INJECTION 10 ML 10ML
|
Professional
|
Both
|
$80.39
|
|
| Hospital Charge Code |
63600101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.14 |
| Max. Negotiated Rate |
$56.27 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Multiplan PHCS |
$48.23
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$56.27
|
| Rate for Payer: UHCCP Medicaid |
$28.14
|
|
|
WATERJET PROSTATE ABLTJ CMPL
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 0421T
|
| Hospital Charge Code |
76102798
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
|
|
WATERJET PROSTATE ABLTJ CMPL
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 0421T
|
| Hospital Charge Code |
76102798
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$343.90 |
| Max. Negotiated Rate |
$11,961.85 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,544.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,961.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,534.64
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$8,544.18
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,253.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
WATERJET PROSTATE ABLTJ CMPL
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 0421T
|
| Hospital Charge Code |
76102798
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
