|
DEXTROSE 5%/LACTATED RIN 500ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003015
|
|
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 RIN 500ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003015
|
|
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% (LVP) 100ML
|
Facility
|
IP
|
$91.10
|
|
|
Service Code
|
NDC 990792337
|
| Hospital Charge Code |
25003002
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$87.46 |
| Rate for Payer: Aetna Commercial |
$70.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.06
|
| Rate for Payer: Cash Price |
$45.55
|
| Rate for Payer: Cigna Commercial |
$75.61
|
| Rate for Payer: First Health Commercial |
$86.54
|
| Rate for Payer: Humana Commercial |
$77.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.17
|
| Rate for Payer: Ohio Health Group HMO |
$68.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.24
|
| Rate for Payer: PHCS Commercial |
$87.46
|
| Rate for Payer: United Healthcare All Payer |
$80.17
|
|
|
DEXTROSE 5% (LVP) 100ML
|
Facility
|
OP
|
$91.10
|
|
|
Service Code
|
NDC 990792337
|
| Hospital Charge Code |
25003002
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$87.46 |
| Rate for Payer: Aetna Commercial |
$70.15
|
| Rate for Payer: Anthem Medicaid |
$31.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.06
|
| Rate for Payer: Cash Price |
$45.55
|
| Rate for Payer: Cigna Commercial |
$75.61
|
| Rate for Payer: First Health Commercial |
$86.54
|
| Rate for Payer: Humana Commercial |
$77.44
|
| Rate for Payer: Humana KY Medicaid |
$31.33
|
| Rate for Payer: Kentucky WC Medicaid |
$31.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.17
|
| Rate for Payer: Ohio Health Group HMO |
$68.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.24
|
| Rate for Payer: PHCS Commercial |
$87.46
|
| Rate for Payer: United Healthcare All Payer |
$80.17
|
|
|
DEXTROSE 5% (LVP) 25ML
|
Facility
|
OP
|
$66.23
|
|
|
Service Code
|
NDC 990792320
|
| Hospital Charge Code |
25003000
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.61 |
| Max. Negotiated Rate |
$63.58 |
| Rate for Payer: Aetna Commercial |
$51.00
|
| Rate for Payer: Anthem Medicaid |
$22.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.66
|
| Rate for Payer: Cash Price |
$33.12
|
| Rate for Payer: Cigna Commercial |
$54.97
|
| Rate for Payer: First Health Commercial |
$62.92
|
| Rate for Payer: Humana Commercial |
$56.30
|
| Rate for Payer: Humana KY Medicaid |
$22.78
|
| Rate for Payer: Kentucky WC Medicaid |
$23.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.28
|
| Rate for Payer: Ohio Health Group HMO |
$49.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.53
|
| Rate for Payer: PHCS Commercial |
$63.58
|
| Rate for Payer: United Healthcare All Payer |
$58.28
|
|
|
DEXTROSE 5% (LVP) 25ML
|
Facility
|
IP
|
$66.23
|
|
|
Service Code
|
NDC 990792320
|
| Hospital Charge Code |
25003000
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.61 |
| Max. Negotiated Rate |
$63.58 |
| Rate for Payer: Aetna Commercial |
$51.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.66
|
| Rate for Payer: Cash Price |
$33.12
|
| Rate for Payer: Cigna Commercial |
$54.97
|
| Rate for Payer: First Health Commercial |
$62.92
|
| Rate for Payer: Humana Commercial |
$56.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.28
|
| Rate for Payer: Ohio Health Group HMO |
$49.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.53
|
| Rate for Payer: PHCS Commercial |
$63.58
|
| Rate for Payer: United Healthcare All Payer |
$58.28
|
|
|
DEXTROSE 5% (LVP) 50ML
|
Facility
|
IP
|
$78.13
|
|
|
Service Code
|
NDC 990792336
|
| Hospital Charge Code |
25003001
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$60.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.94
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cigna Commercial |
$64.85
|
| Rate for Payer: First Health Commercial |
$74.22
|
| Rate for Payer: Humana Commercial |
$66.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.75
|
| Rate for Payer: Ohio Health Group HMO |
$58.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.22
|
| Rate for Payer: PHCS Commercial |
$75.00
|
| Rate for Payer: United Healthcare All Payer |
$68.75
|
|
|
DEXTROSE 5% (LVP) 50ML
|
Facility
|
OP
|
$78.13
|
|
|
Service Code
|
NDC 990792336
|
| Hospital Charge Code |
25003001
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$60.16
|
| Rate for Payer: Anthem Medicaid |
$26.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.94
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cigna Commercial |
$64.85
|
| Rate for Payer: First Health Commercial |
$74.22
|
| Rate for Payer: Humana Commercial |
$66.41
|
| Rate for Payer: Humana KY Medicaid |
$26.87
|
| Rate for Payer: Kentucky WC Medicaid |
$27.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.75
|
| Rate for Payer: Ohio Health Group HMO |
$58.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.22
|
| Rate for Payer: PHCS Commercial |
$75.00
|
| Rate for Payer: United Healthcare All Payer |
$68.75
|
|
|
DEXTROSE 5% SINGLES 1 5%/100ML
|
Facility
|
OP
|
$78.16
|
|
|
Service Code
|
NDC 990792323
|
| Hospital Charge Code |
25003007
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.03 |
| Rate for Payer: Aetna Commercial |
$60.18
|
| Rate for Payer: Anthem Medicaid |
$26.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.96
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.87
|
| Rate for Payer: First Health Commercial |
$74.25
|
| Rate for Payer: Humana Commercial |
$66.44
|
| Rate for Payer: Humana KY Medicaid |
$26.88
|
| Rate for Payer: Kentucky WC Medicaid |
$27.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.78
|
| Rate for Payer: Ohio Health Group HMO |
$58.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.23
|
| Rate for Payer: PHCS Commercial |
$75.03
|
| Rate for Payer: United Healthcare All Payer |
$68.78
|
|
|
DEXTROSE 5% SINGLES 1 5%/100ML
|
Facility
|
IP
|
$78.16
|
|
|
Service Code
|
NDC 990792323
|
| Hospital Charge Code |
25003007
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.03 |
| Rate for Payer: Aetna Commercial |
$60.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.96
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.87
|
| Rate for Payer: First Health Commercial |
$74.25
|
| Rate for Payer: Humana Commercial |
$66.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.78
|
| Rate for Payer: Ohio Health Group HMO |
$58.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.23
|
| Rate for Payer: PHCS Commercial |
$75.03
|
| Rate for Payer: United Healthcare All Payer |
$68.78
|
|
|
DEXTROSE 5%(VISIV)250ML IVSOLN
|
Facility
|
IP
|
$69.14
|
|
|
Service Code
|
NDC 338006230
|
| Hospital Charge Code |
25003008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$66.37 |
| Rate for Payer: Aetna Commercial |
$53.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.93
|
| Rate for Payer: Cash Price |
$34.57
|
| Rate for Payer: Cigna Commercial |
$57.39
|
| Rate for Payer: First Health Commercial |
$65.68
|
| Rate for Payer: Humana Commercial |
$58.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.43
|
| Rate for Payer: PHCS Commercial |
$66.37
|
| Rate for Payer: United Healthcare All Payer |
$60.84
|
|
|
DEXTROSE 5%(VISIV)250ML IVSOLN
|
Facility
|
OP
|
$69.14
|
|
|
Service Code
|
NDC 338006230
|
| Hospital Charge Code |
25003008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$66.37 |
| Rate for Payer: Aetna Commercial |
$53.24
|
| Rate for Payer: Anthem Medicaid |
$23.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.93
|
| Rate for Payer: Cash Price |
$34.57
|
| Rate for Payer: Cigna Commercial |
$57.39
|
| Rate for Payer: First Health Commercial |
$65.68
|
| Rate for Payer: Humana Commercial |
$58.77
|
| Rate for Payer: Humana KY Medicaid |
$23.78
|
| Rate for Payer: Kentucky WC Medicaid |
$24.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.43
|
| Rate for Payer: PHCS Commercial |
$66.37
|
| Rate for Payer: United Healthcare All Payer |
$60.84
|
|
|
DEXTROSE 70% 500ML
|
Facility
|
IP
|
$119.53
|
|
|
Service Code
|
NDC 990791819
|
| Hospital Charge Code |
25003017
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$114.75 |
| Rate for Payer: Aetna Commercial |
$92.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.23
|
| Rate for Payer: Cash Price |
$59.76
|
| Rate for Payer: Cigna Commercial |
$99.21
|
| Rate for Payer: First Health Commercial |
$113.55
|
| Rate for Payer: Humana Commercial |
$101.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.19
|
| Rate for Payer: Ohio Health Group HMO |
$89.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.05
|
| Rate for Payer: PHCS Commercial |
$114.75
|
| Rate for Payer: United Healthcare All Payer |
$105.19
|
|
|
DEXTROSE 70% 500ML
|
Facility
|
OP
|
$119.53
|
|
|
Service Code
|
NDC 990791819
|
| Hospital Charge Code |
25003017
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$114.75 |
| Rate for Payer: Aetna Commercial |
$92.04
|
| Rate for Payer: Anthem Medicaid |
$41.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.23
|
| Rate for Payer: Cash Price |
$59.76
|
| Rate for Payer: Cigna Commercial |
$99.21
|
| Rate for Payer: First Health Commercial |
$113.55
|
| Rate for Payer: Humana Commercial |
$101.60
|
| Rate for Payer: Humana KY Medicaid |
$41.11
|
| Rate for Payer: Kentucky WC Medicaid |
$41.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.19
|
| Rate for Payer: Ohio Health Group HMO |
$89.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.05
|
| Rate for Payer: PHCS Commercial |
$114.75
|
| Rate for Payer: United Healthcare All Payer |
$105.19
|
|
|
DEXTROSE D5/W 0.9% NACL 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003018
|
|
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 D5/W 0.9% NACL 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003018
|
|
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
|
|
|
DGW SV .018 180CM SHORT ST
|
Facility
|
IP
|
$1,125.20
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.28 |
| Max. Negotiated Rate |
$1,080.19 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.66
|
| Rate for Payer: Cash Price |
$562.60
|
| Rate for Payer: Cigna Commercial |
$933.92
|
| Rate for Payer: First Health Commercial |
$1,068.94
|
| Rate for Payer: Humana Commercial |
$956.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.18
|
| Rate for Payer: Ohio Health Group HMO |
$843.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.81
|
| Rate for Payer: PHCS Commercial |
$1,080.19
|
| Rate for Payer: United Healthcare All Payer |
$990.18
|
|
|
DGW SV .018 180CM SHORT ST
|
Facility
|
OP
|
$1,125.20
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.28 |
| Max. Negotiated Rate |
$1,080.19 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Anthem Medicaid |
$386.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.66
|
| Rate for Payer: Cash Price |
$562.60
|
| Rate for Payer: Cigna Commercial |
$933.92
|
| Rate for Payer: First Health Commercial |
$1,068.94
|
| Rate for Payer: Humana Commercial |
$956.42
|
| Rate for Payer: Humana KY Medicaid |
$386.96
|
| Rate for Payer: Kentucky WC Medicaid |
$390.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$394.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.18
|
| Rate for Payer: Ohio Health Group HMO |
$843.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.81
|
| Rate for Payer: PHCS Commercial |
$1,080.19
|
| Rate for Payer: United Healthcare All Payer |
$990.18
|
|
|
DGW SV .018 300CM SHORT ST
|
Facility
|
IP
|
$1,125.20
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.28 |
| Max. Negotiated Rate |
$1,080.19 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.66
|
| Rate for Payer: Cash Price |
$562.60
|
| Rate for Payer: Cigna Commercial |
$933.92
|
| Rate for Payer: First Health Commercial |
$1,068.94
|
| Rate for Payer: Humana Commercial |
$956.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.18
|
| Rate for Payer: Ohio Health Group HMO |
$843.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.81
|
| Rate for Payer: PHCS Commercial |
$1,080.19
|
| Rate for Payer: United Healthcare All Payer |
$990.18
|
|
|
DGW SV .018 300CM SHORT ST
|
Facility
|
OP
|
$1,125.20
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.28 |
| Max. Negotiated Rate |
$1,080.19 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Anthem Medicaid |
$386.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.66
|
| Rate for Payer: Cash Price |
$562.60
|
| Rate for Payer: Cigna Commercial |
$933.92
|
| Rate for Payer: First Health Commercial |
$1,068.94
|
| Rate for Payer: Humana Commercial |
$956.42
|
| Rate for Payer: Humana KY Medicaid |
$386.96
|
| Rate for Payer: Kentucky WC Medicaid |
$390.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$394.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.18
|
| Rate for Payer: Ohio Health Group HMO |
$843.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.81
|
| Rate for Payer: PHCS Commercial |
$1,080.19
|
| Rate for Payer: United Healthcare All Payer |
$990.18
|
|
|
DHE 45(DIHYROERGOTAMIN 1MG/1ML
|
Facility
|
OP
|
$559.35
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
25002018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.72 |
| Max. Negotiated Rate |
$536.98 |
| Rate for Payer: Aetna Commercial |
$430.70
|
| Rate for Payer: Anthem Medicaid |
$192.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.29
|
| Rate for Payer: Cash Price |
$279.68
|
| Rate for Payer: Cigna Commercial |
$464.26
|
| Rate for Payer: First Health Commercial |
$531.38
|
| Rate for Payer: Humana Commercial |
$475.45
|
| Rate for Payer: Humana KY Medicaid |
$192.36
|
| Rate for Payer: Kentucky WC Medicaid |
$194.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.23
|
| Rate for Payer: Ohio Health Group HMO |
$419.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$111.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.40
|
| Rate for Payer: PHCS Commercial |
$536.98
|
| Rate for Payer: United Healthcare All Payer |
$492.23
|
|
|
DHE 45(DIHYROERGOTAMIN 1MG/1ML
|
Facility
|
IP
|
$559.35
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
25002018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.72 |
| Max. Negotiated Rate |
$536.98 |
| Rate for Payer: Aetna Commercial |
$430.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.29
|
| Rate for Payer: Cash Price |
$279.68
|
| Rate for Payer: Cigna Commercial |
$464.26
|
| Rate for Payer: First Health Commercial |
$531.38
|
| Rate for Payer: Humana Commercial |
$475.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.23
|
| Rate for Payer: Ohio Health Group HMO |
$419.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$111.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.40
|
| Rate for Payer: PHCS Commercial |
$536.98
|
| Rate for Payer: United Healthcare All Payer |
$492.23
|
|
|
DHE NASAL 4mg
|
Facility
|
OP
|
$36.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$34.80 |
| Rate for Payer: Aetna Commercial |
$27.91
|
| Rate for Payer: Anthem Medicaid |
$12.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.28
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cigna Commercial |
$30.09
|
| Rate for Payer: First Health Commercial |
$34.44
|
| Rate for Payer: Humana Commercial |
$30.81
|
| Rate for Payer: Humana KY Medicaid |
$12.47
|
| Rate for Payer: Kentucky WC Medicaid |
$12.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.90
|
| Rate for Payer: Ohio Health Group HMO |
$27.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.24
|
| Rate for Payer: PHCS Commercial |
$34.80
|
| Rate for Payer: United Healthcare All Payer |
$31.90
|
|
|
DHE NASAL 4mg
|
Facility
|
IP
|
$36.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$34.80 |
| Rate for Payer: Aetna Commercial |
$27.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.28
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cigna Commercial |
$30.09
|
| Rate for Payer: First Health Commercial |
$34.44
|
| Rate for Payer: Humana Commercial |
$30.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.90
|
| Rate for Payer: Ohio Health Group HMO |
$27.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.24
|
| Rate for Payer: PHCS Commercial |
$34.80
|
| Rate for Payer: United Healthcare All Payer |
$31.90
|
|
|
DIABETA (GLYBURIDE) 2.5MG/1TAB
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 93834301
|
| Hospital Charge Code |
25000549
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| 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 |
$4.19
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
| Rate for Payer: Aetna Commercial |
$3.36
|
|
