|
DAUNORUBICIN 10MG (20MG VIAL)
|
Facility
|
OP
|
$714.71
|
|
|
Service Code
|
HCPCS J9150
|
| Hospital Charge Code |
25002599
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.76 |
| Max. Negotiated Rate |
$686.12 |
| Rate for Payer: Aetna Commercial |
$550.33
|
| Rate for Payer: Anthem Medicaid |
$245.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$19.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$557.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$27.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$26.68
|
| Rate for Payer: Cash Price |
$357.36
|
| Rate for Payer: Cash Price |
$357.36
|
| Rate for Payer: Cigna Commercial |
$593.21
|
| Rate for Payer: First Health Commercial |
$678.97
|
| Rate for Payer: Humana Commercial |
$607.50
|
| Rate for Payer: Humana KY Medicaid |
$245.79
|
| Rate for Payer: Humana Medicare Advantage |
$19.76
|
| Rate for Payer: Kentucky WC Medicaid |
$248.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$586.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$527.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$250.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$628.94
|
| Rate for Payer: Ohio Health Group HMO |
$536.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$571.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$621.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$493.15
|
| Rate for Payer: PHCS Commercial |
$686.12
|
| Rate for Payer: United Healthcare All Payer |
$628.94
|
|
|
DAYPRO (OXAPROZIN) 600MG/1TAB
|
Facility
|
OP
|
$9.47
|
|
|
Service Code
|
NDC 185014101
|
| Hospital Charge Code |
25000517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$7.29
|
| Rate for Payer: Anthem Medicaid |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.39
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.86
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: Humana Commercial |
$8.05
|
| Rate for Payer: Humana KY Medicaid |
$3.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.53
|
| Rate for Payer: PHCS Commercial |
$9.09
|
| Rate for Payer: United Healthcare All Payer |
$8.33
|
|
|
DAYPRO (OXAPROZIN) 600MG/1TAB
|
Facility
|
IP
|
$9.47
|
|
|
Service Code
|
NDC 185014101
|
| Hospital Charge Code |
25000517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$7.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.39
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.86
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: Humana Commercial |
$8.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.53
|
| Rate for Payer: PHCS Commercial |
$9.09
|
| Rate for Payer: United Healthcare All Payer |
$8.33
|
|
|
DBRIDE FISTULECTOMY PR FISTULA
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 45999
|
| Hospital Charge Code |
76103016
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$595.00 |
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
|
|
DBR MUC/FAS UP TO EA AD 20SQCM
|
Facility
|
IP
|
$1,365.00
|
|
|
Service Code
|
HCPCS 11046
|
| Hospital Charge Code |
76100030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$1,310.40 |
| Rate for Payer: Aetna Commercial |
$1,051.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,064.70
|
| Rate for Payer: Cash Price |
$682.50
|
| Rate for Payer: Cigna Commercial |
$1,132.95
|
| Rate for Payer: First Health Commercial |
$1,296.75
|
| Rate for Payer: Humana Commercial |
$1,160.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,119.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,007.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$409.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,201.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,023.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,092.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,187.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$941.85
|
| Rate for Payer: PHCS Commercial |
$1,310.40
|
| Rate for Payer: United Healthcare All Payer |
$1,201.20
|
|
|
DBR MUC/FAS UP TO EA AD 20SQCM
|
Facility
|
OP
|
$1,265.00
|
|
|
Service Code
|
HCPCS 11046
|
| Hospital Charge Code |
761T0030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$379.50 |
| Max. Negotiated Rate |
$1,214.40 |
| Rate for Payer: Aetna Commercial |
$974.05
|
| Rate for Payer: Anthem Medicaid |
$435.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$986.70
|
| Rate for Payer: Cash Price |
$632.50
|
| Rate for Payer: Cigna Commercial |
$1,049.95
|
| Rate for Payer: First Health Commercial |
$1,201.75
|
| Rate for Payer: Humana Commercial |
$1,075.25
|
| Rate for Payer: Humana KY Medicaid |
$435.03
|
| Rate for Payer: Kentucky WC Medicaid |
$439.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,037.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$933.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$379.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$443.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,113.20
|
| Rate for Payer: Ohio Health Group HMO |
$948.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,012.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,100.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$872.85
|
| Rate for Payer: PHCS Commercial |
$1,214.40
|
| Rate for Payer: United Healthcare All Payer |
$1,113.20
|
|
|
DBR MUC/FAS UP TO EA AD 20SQCM
|
Facility
|
IP
|
$1,265.00
|
|
|
Service Code
|
HCPCS 11046
|
| Hospital Charge Code |
761T0030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$379.50 |
| Max. Negotiated Rate |
$1,214.40 |
| Rate for Payer: Aetna Commercial |
$974.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$986.70
|
| Rate for Payer: Cash Price |
$632.50
|
| Rate for Payer: Cigna Commercial |
$1,049.95
|
| Rate for Payer: First Health Commercial |
$1,201.75
|
| Rate for Payer: Humana Commercial |
$1,075.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,037.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$933.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$379.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,113.20
|
| Rate for Payer: Ohio Health Group HMO |
$948.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,012.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,100.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$872.85
|
| Rate for Payer: PHCS Commercial |
$1,214.40
|
| Rate for Payer: United Healthcare All Payer |
$1,113.20
|
|
|
DBR MUC/FAS UP TO EA AD 20SQCM
|
Facility
|
OP
|
$1,365.00
|
|
|
Service Code
|
HCPCS 11046
|
| Hospital Charge Code |
76100030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$1,310.40 |
| Rate for Payer: Aetna Commercial |
$1,051.05
|
| Rate for Payer: Anthem Medicaid |
$469.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,064.70
|
| Rate for Payer: Cash Price |
$682.50
|
| Rate for Payer: Cigna Commercial |
$1,132.95
|
| Rate for Payer: First Health Commercial |
$1,296.75
|
| Rate for Payer: Humana Commercial |
$1,160.25
|
| Rate for Payer: Humana KY Medicaid |
$469.42
|
| Rate for Payer: Kentucky WC Medicaid |
$474.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,119.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,007.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$409.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$478.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,201.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,023.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,092.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,187.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$941.85
|
| Rate for Payer: PHCS Commercial |
$1,310.40
|
| Rate for Payer: United Healthcare All Payer |
$1,201.20
|
|
|
DBR MUC/FAS UP TO EA AD 20SQCM
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 11046
|
| Hospital Charge Code |
761P0030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$90.04 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Ambetter Exchange |
$51.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.21
|
| Rate for Payer: Anthem Medicaid |
$46.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$51.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$51.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$61.69
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$90.04
|
| Rate for Payer: Healthspan PPO |
$51.78
|
| Rate for Payer: Humana Medicaid |
$46.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$51.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.82
|
| Rate for Payer: Molina Healthcare Passport |
$46.88
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.83
|
| Rate for Payer: UHCCP Medicaid |
$29.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$47.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$51.41
|
|
|
DBR MUC/FAS UP TO EA AD 20SQCM
|
Professional
|
Both
|
$1,365.00
|
|
|
Service Code
|
HCPCS 11046
|
| Hospital Charge Code |
76100030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$819.00 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Ambetter Exchange |
$51.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.21
|
| Rate for Payer: Anthem Medicaid |
$46.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$51.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$51.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$61.69
|
| Rate for Payer: Cash Price |
$682.50
|
| Rate for Payer: Cash Price |
$682.50
|
| Rate for Payer: Cigna Commercial |
$90.04
|
| Rate for Payer: Healthspan PPO |
$51.78
|
| Rate for Payer: Humana Medicaid |
$46.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$51.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.82
|
| Rate for Payer: Molina Healthcare Passport |
$46.88
|
| Rate for Payer: Multiplan PHCS |
$819.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.83
|
| Rate for Payer: UHCCP Medicaid |
$29.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$47.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$51.41
|
|
|
DCMPRSSN THIGH/KNEE W/DBRDMT
|
Facility
|
IP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27497
|
| Hospital Charge Code |
76102946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$966.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
DCMPRSSN THIGH/KNEE W/DBRDMT
|
Facility
|
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27497
|
| Hospital Charge Code |
76102946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$481.46 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem Medicaid |
$481.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Humana KY Medicaid |
$481.46
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$486.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$491.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$966.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
DCMPRSSN THIGH/KNEE W/DBRDMT
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27497
|
| Hospital Charge Code |
76102946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$341.46 |
| Max. Negotiated Rate |
$862.84 |
| Rate for Payer: Aetna Commercial |
$797.19
|
| Rate for Payer: Ambetter Exchange |
$555.58
|
| Rate for Payer: Anthem Medicaid |
$341.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$555.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$555.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$666.70
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$862.84
|
| Rate for Payer: Healthspan PPO |
$722.09
|
| Rate for Payer: Humana Medicaid |
$341.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$699.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$555.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$348.29
|
| Rate for Payer: Molina Healthcare Passport |
$341.46
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$722.25
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$344.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$555.58
|
|
|
DDAVP(DESMOPRES ACET)0.2 MGTAB
|
Facility
|
IP
|
$5.02
|
|
|
Service Code
|
NDC 60505025801
|
| Hospital Charge Code |
25000522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.77
|
| Rate for Payer: Humana Commercial |
$4.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.42
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$4.82
|
| Rate for Payer: United Healthcare All Payer |
$4.42
|
|
|
DDAVP(DESMOPRES ACET)0.2 MGTAB
|
Facility
|
OP
|
$5.02
|
|
|
Service Code
|
NDC 60505025801
|
| Hospital Charge Code |
25000522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.77
|
| Rate for Payer: Humana Commercial |
$4.27
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.42
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$4.82
|
| Rate for Payer: United Healthcare All Payer |
$4.42
|
|
|
DDAVP(DESMOPRESSIN .25MG/2.5ML
|
Facility
|
OP
|
$12.30
|
|
|
Service Code
|
NDC 24208034205
|
| Hospital Charge Code |
25002983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$11.81 |
| Rate for Payer: Aetna Commercial |
$9.47
|
| Rate for Payer: Anthem Medicaid |
$4.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.59
|
| Rate for Payer: Cash Price |
$6.15
|
| Rate for Payer: Cigna Commercial |
$10.21
|
| Rate for Payer: First Health Commercial |
$11.69
|
| Rate for Payer: Humana Commercial |
$10.46
|
| Rate for Payer: Humana KY Medicaid |
$4.23
|
| Rate for Payer: Kentucky WC Medicaid |
$4.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.82
|
| Rate for Payer: Ohio Health Group HMO |
$9.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.49
|
| Rate for Payer: PHCS Commercial |
$11.81
|
| Rate for Payer: United Healthcare All Payer |
$10.82
|
|
|
DDAVP(DESMOPRESSIN .25MG/2.5ML
|
Facility
|
IP
|
$12.30
|
|
|
Service Code
|
NDC 24208034205
|
| Hospital Charge Code |
25002983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$11.81 |
| Rate for Payer: Aetna Commercial |
$9.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.59
|
| Rate for Payer: Cash Price |
$6.15
|
| Rate for Payer: Cigna Commercial |
$10.21
|
| Rate for Payer: First Health Commercial |
$11.69
|
| Rate for Payer: Humana Commercial |
$10.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.82
|
| Rate for Payer: Ohio Health Group HMO |
$9.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.49
|
| Rate for Payer: PHCS Commercial |
$11.81
|
| Rate for Payer: United Healthcare All Payer |
$10.82
|
|
|
D DIMER QUANTITATIVE
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 85379
|
| Hospital Charge Code |
30000601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna Commercial |
$134.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.53
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$145.25
|
| Rate for Payer: First Health Commercial |
$166.25
|
| Rate for Payer: Humana Commercial |
$148.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$143.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.00
|
| Rate for Payer: Ohio Health Group HMO |
$131.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.75
|
| Rate for Payer: PHCS Commercial |
$168.00
|
| Rate for Payer: United Healthcare All Payer |
$154.00
|
|
|
D DIMER QUANTITATIVE
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 85379
|
| Hospital Charge Code |
30000601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna Commercial |
$134.75
|
| Rate for Payer: Anthem Medicaid |
$10.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.18
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$145.25
|
| Rate for Payer: First Health Commercial |
$166.25
|
| Rate for Payer: Humana Commercial |
$148.75
|
| Rate for Payer: Humana KY Medicaid |
$10.18
|
| Rate for Payer: Humana Medicare Advantage |
$10.18
|
| Rate for Payer: Kentucky WC Medicaid |
$10.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$143.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.00
|
| Rate for Payer: Ohio Health Group HMO |
$131.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.75
|
| Rate for Payer: PHCS Commercial |
$168.00
|
| Rate for Payer: United Healthcare All Payer |
$154.00
|
|
|
DEBEXT GENIT PERIN ABDOM WALL
|
Facility
|
OP
|
$1,047.00
|
|
|
Service Code
|
HCPCS 11006
|
| Hospital Charge Code |
76100021
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.10 |
| Max. Negotiated Rate |
$1,005.12 |
| Rate for Payer: Aetna Commercial |
$806.19
|
| Rate for Payer: Anthem Medicaid |
$360.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$816.66
|
| Rate for Payer: Cash Price |
$523.50
|
| Rate for Payer: Cigna Commercial |
$869.01
|
| Rate for Payer: First Health Commercial |
$994.65
|
| Rate for Payer: Humana Commercial |
$889.95
|
| Rate for Payer: Humana KY Medicaid |
$360.06
|
| Rate for Payer: Kentucky WC Medicaid |
$363.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$858.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$772.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$314.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$367.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$921.36
|
| Rate for Payer: Ohio Health Group HMO |
$785.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$837.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$910.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$722.43
|
| Rate for Payer: PHCS Commercial |
$1,005.12
|
| Rate for Payer: United Healthcare All Payer |
$921.36
|
|
|
DEBEXT GENIT PERIN ABDOM WALL
|
Professional
|
Both
|
$1,047.00
|
|
|
Service Code
|
HCPCS 11006
|
| Hospital Charge Code |
76100021
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$366.45 |
| Max. Negotiated Rate |
$1,079.67 |
| Rate for Payer: Aetna Commercial |
$1,079.67
|
| Rate for Payer: Ambetter Exchange |
$664.64
|
| Rate for Payer: Anthem Medicaid |
$531.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$664.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$664.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.57
|
| Rate for Payer: Cash Price |
$523.50
|
| Rate for Payer: Cash Price |
$523.50
|
| Rate for Payer: Cigna Commercial |
$1,021.15
|
| Rate for Payer: Healthspan PPO |
$863.30
|
| Rate for Payer: Humana Medicaid |
$531.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$904.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$664.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$664.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$541.67
|
| Rate for Payer: Molina Healthcare Passport |
$531.05
|
| Rate for Payer: Multiplan PHCS |
$628.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$864.03
|
| Rate for Payer: UHCCP Medicaid |
$366.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$536.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$664.64
|
|
|
DEBEXT GENIT PERIN ABDOM WALL
|
Facility
|
IP
|
$1,047.00
|
|
|
Service Code
|
HCPCS 11006
|
| Hospital Charge Code |
76100021
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.10 |
| Max. Negotiated Rate |
$1,005.12 |
| Rate for Payer: Aetna Commercial |
$806.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$816.66
|
| Rate for Payer: Cash Price |
$523.50
|
| Rate for Payer: Cigna Commercial |
$869.01
|
| Rate for Payer: First Health Commercial |
$994.65
|
| Rate for Payer: Humana Commercial |
$889.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$858.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$772.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$314.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$921.36
|
| Rate for Payer: Ohio Health Group HMO |
$785.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$837.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$910.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$722.43
|
| Rate for Payer: PHCS Commercial |
$1,005.12
|
| Rate for Payer: United Healthcare All Payer |
$921.36
|
|
|
DEBEXT GENIT PERIN ABDOM WAL(P
|
Professional
|
Both
|
$1,047.00
|
|
|
Service Code
|
HCPCS 11006
|
| Hospital Charge Code |
761P0021
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$366.45 |
| Max. Negotiated Rate |
$1,079.67 |
| Rate for Payer: Aetna Commercial |
$1,079.67
|
| Rate for Payer: Ambetter Exchange |
$664.64
|
| Rate for Payer: Anthem Medicaid |
$531.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$664.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$664.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.57
|
| Rate for Payer: Cash Price |
$523.50
|
| Rate for Payer: Cash Price |
$523.50
|
| Rate for Payer: Cigna Commercial |
$1,021.15
|
| Rate for Payer: Healthspan PPO |
$863.30
|
| Rate for Payer: Humana Medicaid |
$531.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$904.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$664.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$664.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$541.67
|
| Rate for Payer: Molina Healthcare Passport |
$531.05
|
| Rate for Payer: Multiplan PHCS |
$628.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$864.03
|
| Rate for Payer: UHCCP Medicaid |
$366.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$536.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$664.64
|
|
|
DEBR BONE 1ST 20 SQ CM OR <
|
Facility
|
IP
|
$4,024.00
|
|
|
Service Code
|
HCPCS 11044
|
| Hospital Charge Code |
76100028
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,207.20 |
| Max. Negotiated Rate |
$3,863.04 |
| Rate for Payer: Aetna Commercial |
$3,098.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,138.72
|
| Rate for Payer: Cash Price |
$2,012.00
|
| Rate for Payer: Cigna Commercial |
$3,339.92
|
| Rate for Payer: First Health Commercial |
$3,822.80
|
| Rate for Payer: Humana Commercial |
$3,420.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,299.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,969.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,207.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,541.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,018.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,219.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,500.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,776.56
|
| Rate for Payer: PHCS Commercial |
$3,863.04
|
| Rate for Payer: United Healthcare All Payer |
$3,541.12
|
|
|
DEBR BONE 1ST 20 SQ CM OR <
|
Professional
|
Both
|
$4,024.00
|
|
|
Service Code
|
HCPCS 11044
|
| Hospital Charge Code |
76100028
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$2,414.40 |
| Rate for Payer: Aetna Commercial |
$463.23
|
| Rate for Payer: Ambetter Exchange |
$212.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.20
|
| Rate for Payer: Anthem Medicaid |
$154.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$212.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$212.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$255.18
|
| Rate for Payer: Cash Price |
$2,012.00
|
| Rate for Payer: Cash Price |
$2,012.00
|
| Rate for Payer: Cigna Commercial |
$448.50
|
| Rate for Payer: Healthspan PPO |
$417.47
|
| Rate for Payer: Humana Medicaid |
$154.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$267.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$212.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$212.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$157.54
|
| Rate for Payer: Molina Healthcare Passport |
$154.45
|
| Rate for Payer: Multiplan PHCS |
$2,414.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$276.44
|
| Rate for Payer: UHCCP Medicaid |
$122.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$155.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$212.65
|
|
