|
DEXTROSE 10% (FS) 1000ML
|
Facility
|
IP
|
$5.25
|
|
|
Service Code
|
NDC 990793009
|
| Hospital Charge Code |
25002993
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$4.36
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: First Health Commercial |
$4.99
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana Commercial |
$4.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.63
|
| Rate for Payer: PHCS Commercial |
$5.04
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 25% 2.5GM (INFANT)SYR
|
Facility
|
IP
|
$34.01
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
25002995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$32.65 |
| Rate for Payer: Aetna Commercial |
$26.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.53
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna Commercial |
$28.23
|
| Rate for Payer: First Health Commercial |
$32.31
|
| Rate for Payer: Humana Commercial |
$28.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.93
|
| Rate for Payer: Ohio Health Group HMO |
$25.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.54
|
| Rate for Payer: PHCS Commercial |
$32.65
|
| Rate for Payer: United Healthcare All Payer |
$29.93
|
|
|
DEXTROSE 25% 2.5GM (INFANT)SYR
|
Facility
|
OP
|
$34.01
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
25002995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$32.65 |
| Rate for Payer: Aetna Commercial |
$26.19
|
| Rate for Payer: Anthem Medicaid |
$11.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.53
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna Commercial |
$28.23
|
| Rate for Payer: First Health Commercial |
$32.31
|
| Rate for Payer: Humana Commercial |
$28.91
|
| Rate for Payer: Humana KY Medicaid |
$11.70
|
| Rate for Payer: Kentucky WC Medicaid |
$11.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.93
|
| Rate for Payer: Ohio Health Group HMO |
$25.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.54
|
| Rate for Payer: PHCS Commercial |
$32.65
|
| Rate for Payer: United Healthcare All Payer |
$29.93
|
|
|
DEXTROSE 25GM/50ML VL
|
Facility
|
IP
|
$80.31
|
|
|
Service Code
|
NDC 409664802
|
| Hospital Charge Code |
25002996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.44 |
| Max. Negotiated Rate |
$77.10 |
| Rate for Payer: Aetna Commercial |
$61.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.64
|
| Rate for Payer: Cash Price |
$40.16
|
| Rate for Payer: Cigna Commercial |
$66.66
|
| Rate for Payer: First Health Commercial |
$76.29
|
| Rate for Payer: Humana Commercial |
$68.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.67
|
| Rate for Payer: Ohio Health Group HMO |
$60.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.90
|
| Rate for Payer: PHCS Commercial |
$77.10
|
| Rate for Payer: United Healthcare All Payer |
$70.67
|
|
|
DEXTROSE 25GM/50ML VL
|
Facility
|
OP
|
$80.31
|
|
|
Service Code
|
NDC 409664802
|
| Hospital Charge Code |
25002996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.44 |
| Max. Negotiated Rate |
$77.10 |
| Rate for Payer: Aetna Commercial |
$61.84
|
| Rate for Payer: Anthem Medicaid |
$27.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.64
|
| Rate for Payer: Cash Price |
$40.16
|
| Rate for Payer: Cigna Commercial |
$66.66
|
| Rate for Payer: First Health Commercial |
$76.29
|
| Rate for Payer: Humana Commercial |
$68.26
|
| Rate for Payer: Humana KY Medicaid |
$27.62
|
| Rate for Payer: Kentucky WC Medicaid |
$27.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.67
|
| Rate for Payer: Ohio Health Group HMO |
$60.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.90
|
| Rate for Payer: PHCS Commercial |
$77.10
|
| Rate for Payer: United Healthcare All Payer |
$70.67
|
|
|
DEXTROSE 50% (25GM/50ML) SYR
|
Facility
|
IP
|
$125.42
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$120.40 |
| Rate for Payer: Aetna Commercial |
$96.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.83
|
| Rate for Payer: Cash Price |
$62.71
|
| Rate for Payer: Cigna Commercial |
$104.10
|
| Rate for Payer: First Health Commercial |
$119.15
|
| Rate for Payer: Humana Commercial |
$106.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.37
|
| Rate for Payer: Ohio Health Group HMO |
$94.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.88
|
| Rate for Payer: PHCS Commercial |
$120.40
|
| Rate for Payer: United Healthcare All Payer |
$110.37
|
|
|
DEXTROSE 50% (25GM/50ML) SYR
|
Facility
|
OP
|
$125.42
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$120.40 |
| Rate for Payer: Aetna Commercial |
$96.57
|
| Rate for Payer: Anthem Medicaid |
$43.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.83
|
| Rate for Payer: Cash Price |
$62.71
|
| Rate for Payer: Cigna Commercial |
$104.10
|
| Rate for Payer: First Health Commercial |
$119.15
|
| Rate for Payer: Humana Commercial |
$106.61
|
| Rate for Payer: Humana KY Medicaid |
$43.13
|
| Rate for Payer: Kentucky WC Medicaid |
$43.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.37
|
| Rate for Payer: Ohio Health Group HMO |
$94.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.88
|
| Rate for Payer: PHCS Commercial |
$120.40
|
| Rate for Payer: United Healthcare All Payer |
$110.37
|
|
|
DEXTROSE 5%/0.2% NACL (F 500ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.2% NACL (F 500ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.45% NACL 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.45% NACL 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
|
|
DEXTROSE 5%/0.45% NACL ( 500ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.45% NACL ( 500ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.9% NACL (F 500ML
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.83
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
DEXTROSE 5%/0.9% NACL (F 500ML
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$31.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$31.98
|
| Rate for Payer: Kentucky WC Medicaid |
$32.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.83
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
DEXTROSE 5% (FS) 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
25002997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (FS) 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
25002997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% GLASS (IVPB) 107ML
|
Facility
|
IP
|
$66.47
|
|
|
Service Code
|
NDC 264151032
|
| Hospital Charge Code |
25003005
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$63.81 |
| Rate for Payer: Humana Commercial |
$56.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.49
|
| Rate for Payer: Ohio Health Group HMO |
$49.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.61
|
| Rate for Payer: PHCS Commercial |
$63.81
|
| Rate for Payer: United Healthcare All Payer |
$58.49
|
| Rate for Payer: Aetna Commercial |
$51.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.85
|
| Rate for Payer: Cash Price |
$33.24
|
| Rate for Payer: Cigna Commercial |
$55.17
|
| Rate for Payer: First Health Commercial |
$63.15
|
|
|
DEXTROSE 5% GLASS (IVPB) 107ML
|
Facility
|
OP
|
$66.47
|
|
|
Service Code
|
NDC 264151032
|
| Hospital Charge Code |
25003005
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$63.81 |
| Rate for Payer: Aetna Commercial |
$51.18
|
| Rate for Payer: Anthem Medicaid |
$22.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.85
|
| Rate for Payer: Cash Price |
$33.24
|
| Rate for Payer: Cigna Commercial |
$55.17
|
| Rate for Payer: First Health Commercial |
$63.15
|
| Rate for Payer: Humana Commercial |
$56.50
|
| Rate for Payer: Humana KY Medicaid |
$22.86
|
| Rate for Payer: Kentucky WC Medicaid |
$23.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.49
|
| Rate for Payer: Ohio Health Group HMO |
$49.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.61
|
| Rate for Payer: PHCS Commercial |
$63.81
|
| Rate for Payer: United Healthcare All Payer |
$58.49
|
|
|
DEXTROSE 5% (IVPB) 280ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (IVPB) 280ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
|
|
DEXTROSE 5% (IVPB) 500ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (IVPB) 500ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/LACTATED RI 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/LACTATED RI 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
