|
DITROPAN XL (OXYBUTYNIN) 5MG T
|
Facility
|
IP
|
$10.57
|
|
|
Service Code
|
NDC 68084048001
|
| Hospital Charge Code |
25000574
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$8.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Cash Price |
$5.28
|
| Rate for Payer: Cigna Commercial |
$8.77
|
| Rate for Payer: First Health Commercial |
$10.04
|
| Rate for Payer: Humana Commercial |
$8.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$10.15
|
| Rate for Payer: United Healthcare All Payer |
$9.30
|
|
|
DITROPAN XL (OXYBUTYNIN) 5MG T
|
Facility
|
OP
|
$10.57
|
|
|
Service Code
|
NDC 68084048001
|
| Hospital Charge Code |
25000574
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$8.14
|
| Rate for Payer: Anthem Medicaid |
$3.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Cash Price |
$5.28
|
| Rate for Payer: Cigna Commercial |
$8.77
|
| Rate for Payer: First Health Commercial |
$10.04
|
| Rate for Payer: Humana Commercial |
$8.98
|
| Rate for Payer: Humana KY Medicaid |
$3.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$10.15
|
| Rate for Payer: United Healthcare All Payer |
$9.30
|
|
|
DIURIL (CHLOROTHIA 500MG/1VIAL
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
HCPCS J1205
|
| Hospital Charge Code |
25002035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.77 |
| Max. Negotiated Rate |
$315.84 |
| Rate for Payer: Aetna Commercial |
$253.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.62
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$273.07
|
| Rate for Payer: First Health Commercial |
$312.55
|
| Rate for Payer: Humana Commercial |
$279.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.52
|
| Rate for Payer: Ohio Health Group HMO |
$246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.99
|
| Rate for Payer: PHCS Commercial |
$315.84
|
| Rate for Payer: United Healthcare All Payer |
$289.52
|
|
|
DIURIL (CHLOROTHIA 500MG/1VIAL
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
HCPCS J1205
|
| Hospital Charge Code |
25002035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.77 |
| Max. Negotiated Rate |
$315.84 |
| Rate for Payer: Aetna Commercial |
$253.33
|
| Rate for Payer: Anthem Medicaid |
$113.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.62
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$273.07
|
| Rate for Payer: First Health Commercial |
$312.55
|
| Rate for Payer: Humana Commercial |
$279.65
|
| Rate for Payer: Humana KY Medicaid |
$113.14
|
| Rate for Payer: Kentucky WC Medicaid |
$114.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.52
|
| Rate for Payer: Ohio Health Group HMO |
$246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.99
|
| Rate for Payer: PHCS Commercial |
$315.84
|
| Rate for Payer: United Healthcare All Payer |
$289.52
|
|
|
DLTA TS CER HED 12/14 28MM 8.5
|
Facility
|
OP
|
$10,905.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.76 |
| Max. Negotiated Rate |
$10,469.64 |
| Rate for Payer: Aetna Commercial |
$8,397.52
|
| Rate for Payer: Anthem Medicaid |
$3,750.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,506.58
|
| Rate for Payer: Cash Price |
$5,452.94
|
| Rate for Payer: Cigna Commercial |
$9,051.87
|
| Rate for Payer: First Health Commercial |
$10,360.58
|
| Rate for Payer: Humana Commercial |
$9,269.99
|
| Rate for Payer: Humana KY Medicaid |
$3,750.53
|
| Rate for Payer: Kentucky WC Medicaid |
$3,788.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,942.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,048.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,271.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,825.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,597.17
|
| Rate for Payer: Ohio Health Group HMO |
$8,179.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,181.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,380.82
|
| Rate for Payer: PHCS Commercial |
$10,469.64
|
| Rate for Payer: United Healthcare All Payer |
$9,597.17
|
|
|
DLTA TS CER HED 12/14 28MM 8.5
|
Facility
|
IP
|
$10,905.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.76 |
| Max. Negotiated Rate |
$10,469.64 |
| Rate for Payer: Aetna Commercial |
$8,397.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,506.58
|
| Rate for Payer: Cash Price |
$5,452.94
|
| Rate for Payer: Cigna Commercial |
$9,051.87
|
| Rate for Payer: First Health Commercial |
$10,360.58
|
| Rate for Payer: Humana Commercial |
$9,269.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,942.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,048.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,271.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,597.17
|
| Rate for Payer: Ohio Health Group HMO |
$8,179.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,181.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,380.82
|
| Rate for Payer: PHCS Commercial |
$10,469.64
|
| Rate for Payer: United Healthcare All Payer |
$9,597.17
|
|
|
DLTA TS CER. HED 12/14 44MM 12
|
Facility
|
IP
|
$15,468.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,010.84 |
| Max. Negotiated Rate |
$14,849.28 |
| Rate for Payer: Aetna Commercial |
$11,910.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,065.04
|
| Rate for Payer: Cash Price |
$7,734.00
|
| Rate for Payer: Cigna Commercial |
$12,838.44
|
| Rate for Payer: First Health Commercial |
$14,694.60
|
| Rate for Payer: Humana Commercial |
$13,147.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,683.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,415.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,640.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,611.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,601.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,093.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,010.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,795.08
|
| Rate for Payer: PHCS Commercial |
$14,849.28
|
| Rate for Payer: United Healthcare All Payer |
$13,611.84
|
|
|
DLTA TS CER. HED 12/14 44MM 12
|
Facility
|
OP
|
$15,468.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,010.84 |
| Max. Negotiated Rate |
$14,849.28 |
| Rate for Payer: Aetna Commercial |
$11,910.36
|
| Rate for Payer: Anthem Medicaid |
$5,319.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,065.04
|
| Rate for Payer: Cash Price |
$7,734.00
|
| Rate for Payer: Cigna Commercial |
$12,838.44
|
| Rate for Payer: First Health Commercial |
$14,694.60
|
| Rate for Payer: Humana Commercial |
$13,147.80
|
| Rate for Payer: Humana KY Medicaid |
$5,319.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,373.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,683.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,415.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,640.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,426.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,611.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,601.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,093.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,010.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,795.08
|
| Rate for Payer: PHCS Commercial |
$14,849.28
|
| Rate for Payer: United Healthcare All Payer |
$13,611.84
|
|
|
DLTA TS CER HED 12/14 44MM+1.5
|
Facility
|
OP
|
$19,586.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,546.20 |
| Max. Negotiated Rate |
$18,802.70 |
| Rate for Payer: Aetna Commercial |
$15,081.34
|
| Rate for Payer: Anthem Medicaid |
$6,735.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,277.20
|
| Rate for Payer: Cash Price |
$9,793.08
|
| Rate for Payer: Cigna Commercial |
$16,256.50
|
| Rate for Payer: First Health Commercial |
$18,606.84
|
| Rate for Payer: Humana Commercial |
$16,648.23
|
| Rate for Payer: Humana KY Medicaid |
$6,735.68
|
| Rate for Payer: Kentucky WC Medicaid |
$6,804.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,060.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,454.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,875.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,870.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,235.81
|
| Rate for Payer: Ohio Health Group HMO |
$14,689.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,917.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,546.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,071.71
|
| Rate for Payer: PHCS Commercial |
$18,802.70
|
| Rate for Payer: United Healthcare All Payer |
$17,235.81
|
|
|
DLTA TS CER HED 12/14 44MM+1.5
|
Facility
|
IP
|
$19,586.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,546.20 |
| Max. Negotiated Rate |
$18,802.70 |
| Rate for Payer: Aetna Commercial |
$15,081.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,277.20
|
| Rate for Payer: Cash Price |
$9,793.08
|
| Rate for Payer: Cigna Commercial |
$16,256.50
|
| Rate for Payer: First Health Commercial |
$18,606.84
|
| Rate for Payer: Humana Commercial |
$16,648.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,060.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,454.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,875.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,235.81
|
| Rate for Payer: Ohio Health Group HMO |
$14,689.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,917.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,546.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,071.71
|
| Rate for Payer: PHCS Commercial |
$18,802.70
|
| Rate for Payer: United Healthcare All Payer |
$17,235.81
|
|
|
DLTA TS CER HED 12/14 44MM 8.5
|
Facility
|
IP
|
$15,468.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,010.84 |
| Max. Negotiated Rate |
$14,849.28 |
| Rate for Payer: Aetna Commercial |
$11,910.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,065.04
|
| Rate for Payer: Cash Price |
$7,734.00
|
| Rate for Payer: Cigna Commercial |
$12,838.44
|
| Rate for Payer: First Health Commercial |
$14,694.60
|
| Rate for Payer: Humana Commercial |
$13,147.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,683.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,415.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,640.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,611.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,601.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,093.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,010.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,795.08
|
| Rate for Payer: PHCS Commercial |
$14,849.28
|
| Rate for Payer: United Healthcare All Payer |
$13,611.84
|
|
|
DLTA TS CER HED 12/14 44MM 8.5
|
Facility
|
OP
|
$15,468.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,010.84 |
| Max. Negotiated Rate |
$14,849.28 |
| Rate for Payer: Aetna Commercial |
$11,910.36
|
| Rate for Payer: Anthem Medicaid |
$5,319.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,065.04
|
| Rate for Payer: Cash Price |
$7,734.00
|
| Rate for Payer: Cigna Commercial |
$12,838.44
|
| Rate for Payer: First Health Commercial |
$14,694.60
|
| Rate for Payer: Humana Commercial |
$13,147.80
|
| Rate for Payer: Humana KY Medicaid |
$5,319.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,373.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,683.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,415.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,640.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,426.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,611.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,601.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,093.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,010.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,795.08
|
| Rate for Payer: PHCS Commercial |
$14,849.28
|
| Rate for Payer: United Healthcare All Payer |
$13,611.84
|
|
|
DLYD PLMT XTN PROSTH 1ST VSL
|
Professional
|
Both
|
$2,256.00
|
|
|
Service Code
|
HCPCS 34710
|
| Hospital Charge Code |
76102656
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$643.15 |
| Max. Negotiated Rate |
$2,256.00 |
| Rate for Payer: Anthem Medicaid |
$643.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,256.00
|
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: Cigna Commercial |
$1,471.61
|
| Rate for Payer: Humana Medicaid |
$643.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,072.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$656.01
|
| Rate for Payer: Molina Healthcare Passport |
$643.15
|
| Rate for Payer: Multiplan PHCS |
$1,353.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,579.20
|
| Rate for Payer: UHCCP Medicaid |
$789.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$649.58
|
|
|
DLY TREATMNT 2 AREAS 6-10 MEV
|
Facility
|
OP
|
$336.00
|
|
|
Service Code
|
HCPCS 77407
|
| Hospital Charge Code |
33300025
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$325.36 |
| Rate for Payer: Aetna Commercial |
$258.72
|
| Rate for Payer: Anthem Medicaid |
$115.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.74
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$278.88
|
| Rate for Payer: First Health Commercial |
$319.20
|
| Rate for Payer: Humana Commercial |
$285.60
|
| Rate for Payer: Humana KY Medicaid |
$115.55
|
| Rate for Payer: Humana Medicare Advantage |
$232.40
|
| Rate for Payer: Kentucky WC Medicaid |
$116.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$275.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$295.68
|
| Rate for Payer: Ohio Health Group HMO |
$252.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.16
|
| Rate for Payer: PHCS Commercial |
$322.56
|
| Rate for Payer: United Healthcare All Payer |
$295.68
|
|
|
DLY TREATMNT 2 AREAS 6-10 MEV
|
Facility
|
IP
|
$336.00
|
|
|
Service Code
|
HCPCS 77407
|
| Hospital Charge Code |
33300025
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$322.56 |
| Rate for Payer: Aetna Commercial |
$258.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.08
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$278.88
|
| Rate for Payer: First Health Commercial |
$319.20
|
| Rate for Payer: Humana Commercial |
$285.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$275.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$295.68
|
| Rate for Payer: Ohio Health Group HMO |
$252.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.16
|
| Rate for Payer: PHCS Commercial |
$322.56
|
| Rate for Payer: United Healthcare All Payer |
$295.68
|
|
|
DLY TRTMNT 3 AREAS 11-19 MEV
|
Facility
|
OP
|
$755.00
|
|
|
Service Code
|
HCPCS 77412
|
| Hospital Charge Code |
33300026
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$98.15 |
| Max. Negotiated Rate |
$724.80 |
| Rate for Payer: Aetna Commercial |
$581.35
|
| Rate for Payer: Anthem Medicaid |
$259.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$588.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.74
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cigna Commercial |
$626.65
|
| Rate for Payer: First Health Commercial |
$717.25
|
| Rate for Payer: Humana Commercial |
$641.75
|
| Rate for Payer: Humana KY Medicaid |
$259.64
|
| Rate for Payer: Humana Medicare Advantage |
$232.40
|
| Rate for Payer: Kentucky WC Medicaid |
$262.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$619.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$557.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$264.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$664.40
|
| Rate for Payer: Ohio Health Group HMO |
$566.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.05
|
| Rate for Payer: PHCS Commercial |
$724.80
|
| Rate for Payer: United Healthcare All Payer |
$664.40
|
|
|
DLY TRTMNT 3 AREAS 11-19 MEV
|
Facility
|
IP
|
$755.00
|
|
|
Service Code
|
HCPCS 77412
|
| Hospital Charge Code |
33300026
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$98.15 |
| Max. Negotiated Rate |
$724.80 |
| Rate for Payer: Aetna Commercial |
$581.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$588.90
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cigna Commercial |
$626.65
|
| Rate for Payer: First Health Commercial |
$717.25
|
| Rate for Payer: Humana Commercial |
$641.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$619.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$557.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$226.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$664.40
|
| Rate for Payer: Ohio Health Group HMO |
$566.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.05
|
| Rate for Payer: PHCS Commercial |
$724.80
|
| Rate for Payer: United Healthcare All Payer |
$664.40
|
|
|
DM RN EDUC 30MIN CORESOURCE/SP
|
Professional
|
Both
|
$103.50
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
76102511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$22.53 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna Commercial |
$35.51
|
| Rate for Payer: Anthem Medicaid |
$22.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$103.50
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cigna Commercial |
$23.51
|
| Rate for Payer: Humana Medicaid |
$22.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$32.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.98
|
| Rate for Payer: Molina Healthcare Passport |
$22.53
|
| Rate for Payer: Multiplan PHCS |
$62.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.45
|
| Rate for Payer: UHCCP Medicaid |
$36.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.76
|
|
|
DM RN EDUC 30MIN CORESOURCE/SP
|
Facility
|
IP
|
$103.50
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
76102511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.46 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$79.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.73
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cigna Commercial |
$85.90
|
| Rate for Payer: First Health Commercial |
$98.32
|
| Rate for Payer: Humana Commercial |
$87.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.08
|
| Rate for Payer: Ohio Health Group HMO |
$77.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.08
|
| Rate for Payer: PHCS Commercial |
$99.36
|
| Rate for Payer: United Healthcare All Payer |
$91.08
|
|
|
DM RN EDUC 30MIN CORESOURCE/SP
|
Facility
|
OP
|
$103.50
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
76102511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.46 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$79.70
|
| Rate for Payer: Anthem Medicaid |
$35.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.73
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cigna Commercial |
$85.90
|
| Rate for Payer: First Health Commercial |
$98.32
|
| Rate for Payer: Humana Commercial |
$87.98
|
| Rate for Payer: Humana KY Medicaid |
$35.59
|
| Rate for Payer: Kentucky WC Medicaid |
$35.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.08
|
| Rate for Payer: Ohio Health Group HMO |
$77.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.08
|
| Rate for Payer: PHCS Commercial |
$99.36
|
| Rate for Payer: United Healthcare All Payer |
$91.08
|
|
|
DOBUTAMINE-DXTRSE 1000MG/250ML
|
Facility
|
OP
|
$185.23
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$177.82 |
| Rate for Payer: Aetna Commercial |
$142.63
|
| Rate for Payer: Anthem Medicaid |
$63.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.48
|
| Rate for Payer: Cash Price |
$92.61
|
| Rate for Payer: Cigna Commercial |
$153.74
|
| Rate for Payer: First Health Commercial |
$175.97
|
| Rate for Payer: Humana Commercial |
$157.45
|
| Rate for Payer: Humana KY Medicaid |
$63.70
|
| Rate for Payer: Kentucky WC Medicaid |
$64.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.00
|
| Rate for Payer: Ohio Health Group HMO |
$138.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.42
|
| Rate for Payer: PHCS Commercial |
$177.82
|
| Rate for Payer: United Healthcare All Payer |
$163.00
|
|
|
DOBUTAMINE-DXTRSE 1000MG/250ML
|
Facility
|
IP
|
$185.23
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$177.82 |
| Rate for Payer: Aetna Commercial |
$142.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.48
|
| Rate for Payer: Cash Price |
$92.61
|
| Rate for Payer: Cigna Commercial |
$153.74
|
| Rate for Payer: First Health Commercial |
$175.97
|
| Rate for Payer: Humana Commercial |
$157.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.00
|
| Rate for Payer: Ohio Health Group HMO |
$138.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.42
|
| Rate for Payer: PHCS Commercial |
$177.82
|
| Rate for Payer: United Healthcare All Payer |
$163.00
|
|
|
DOBUTREX (DOBUTAMIN 250MG/20ML
|
Facility
|
IP
|
$113.93
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$109.37 |
| Rate for Payer: Aetna Commercial |
$87.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.87
|
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: First Health Commercial |
$108.23
|
| Rate for Payer: Humana Commercial |
$96.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.26
|
| Rate for Payer: Ohio Health Group HMO |
$85.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.32
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
DOBUTREX (DOBUTAMIN 250MG/20ML
|
Facility
|
OP
|
$113.93
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$109.37 |
| Rate for Payer: Aetna Commercial |
$87.73
|
| Rate for Payer: Anthem Medicaid |
$39.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.87
|
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: First Health Commercial |
$108.23
|
| Rate for Payer: Humana Commercial |
$96.84
|
| Rate for Payer: Humana KY Medicaid |
$39.18
|
| Rate for Payer: Kentucky WC Medicaid |
$39.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.26
|
| Rate for Payer: Ohio Health Group HMO |
$85.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.32
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
DOCETAXEL 1mg (20mg/2mL SDV)
|
Facility
|
OP
|
$380.30
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.44 |
| Max. Negotiated Rate |
$365.09 |
| Rate for Payer: Aetna Commercial |
$292.83
|
| Rate for Payer: Anthem Medicaid |
$130.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.63
|
| Rate for Payer: Cash Price |
$190.15
|
| Rate for Payer: Cigna Commercial |
$315.65
|
| Rate for Payer: First Health Commercial |
$361.28
|
| Rate for Payer: Humana Commercial |
$323.26
|
| Rate for Payer: Humana KY Medicaid |
$130.79
|
| Rate for Payer: Kentucky WC Medicaid |
$132.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$133.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.66
|
| Rate for Payer: Ohio Health Group HMO |
$285.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$117.89
|
| Rate for Payer: PHCS Commercial |
$365.09
|
| Rate for Payer: United Healthcare All Payer |
$334.66
|
|
