|
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
|
|
|
DOCETAXEL 1mg (from 160mg MDV)
|
Facility
|
IP
|
$5.78
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.51
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna Commercial |
$4.80
|
| Rate for Payer: First Health Commercial |
$5.49
|
| Rate for Payer: Humana Commercial |
$4.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.09
|
| Rate for Payer: Ohio Health Group HMO |
$4.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.79
|
| Rate for Payer: PHCS Commercial |
$5.55
|
| Rate for Payer: United Healthcare All Payer |
$5.09
|
|
|
DOCETAXEL 1mg (from 160mg MDV)
|
Facility
|
OP
|
$5.78
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Anthem Medicaid |
$1.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.51
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna Commercial |
$4.80
|
| Rate for Payer: First Health Commercial |
$5.49
|
| Rate for Payer: Humana Commercial |
$4.91
|
| Rate for Payer: Humana KY Medicaid |
$1.99
|
| Rate for Payer: Kentucky WC Medicaid |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.09
|
| Rate for Payer: Ohio Health Group HMO |
$4.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.79
|
| Rate for Payer: PHCS Commercial |
$5.55
|
| Rate for Payer: United Healthcare All Payer |
$5.09
|
|
|
DOC EXT. WIRE
|
Facility
|
OP
|
$1,565.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.45 |
| Max. Negotiated Rate |
$1,502.40 |
| Rate for Payer: Aetna Commercial |
$1,205.05
|
| Rate for Payer: Anthem Medicaid |
$538.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,220.70
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,298.95
|
| Rate for Payer: First Health Commercial |
$1,486.75
|
| Rate for Payer: Humana Commercial |
$1,330.25
|
| Rate for Payer: Humana KY Medicaid |
$538.20
|
| Rate for Payer: Kentucky WC Medicaid |
$543.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,283.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$549.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,377.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$313.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$485.15
|
| Rate for Payer: PHCS Commercial |
$1,502.40
|
| Rate for Payer: United Healthcare All Payer |
$1,377.20
|
|
|
DOC EXT. WIRE
|
Facility
|
IP
|
$1,565.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.45 |
| Max. Negotiated Rate |
$1,502.40 |
| Rate for Payer: Aetna Commercial |
$1,205.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,220.70
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,298.95
|
| Rate for Payer: First Health Commercial |
$1,486.75
|
| Rate for Payer: Humana Commercial |
$1,330.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,283.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,377.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$313.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$485.15
|
| Rate for Payer: PHCS Commercial |
$1,502.40
|
| Rate for Payer: United Healthcare All Payer |
$1,377.20
|
|
|
DOC WIRE RUNTHROUGH
|
Facility
|
OP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem Medicaid |
$526.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Humana KY Medicaid |
$526.17
|
| Rate for Payer: Kentucky WC Medicaid |
$531.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$536.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
DOC WIRE RUNTHROUGH
|
Facility
|
IP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
DOGDANDER IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000730
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
DOGDANDER IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000730
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
DOLOBID (DIFLUNISAL 500MG/1TAB
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
NDC 93922201
|
| Hospital Charge Code |
25000578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
DOLOBID (DIFLUNISAL 500MG/1TAB
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
NDC 93922201
|
| Hospital Charge Code |
25000578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem Medicaid |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Humana KY Medicaid |
$3.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
DOMEBORO POWDER PACK 2.2GM/1EA
|
Facility
|
IP
|
$4.87
|
|
|
Service Code
|
NDC 16864024001
|
| Hospital Charge Code |
25000579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DOMEBORO POWDER PACK 2.2GM/1EA
|
Facility
|
OP
|
$4.87
|
|
|
Service Code
|
NDC 16864024001
|
| Hospital Charge Code |
25000579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
| Rate for Payer: Aetna Commercial |
$3.75
|
|
|
DONNATAL (BELLAD/PB) ELIXI 5ML
|
Facility
|
IP
|
$11.07
|
|
|
Service Code
|
NDC 50742066516
|
| Hospital Charge Code |
25003026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Aetna Commercial |
$8.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.63
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.19
|
| Rate for Payer: First Health Commercial |
$10.52
|
| Rate for Payer: Humana Commercial |
$9.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.74
|
| Rate for Payer: Ohio Health Group HMO |
$8.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.43
|
| Rate for Payer: PHCS Commercial |
$10.63
|
| Rate for Payer: United Healthcare All Payer |
$9.74
|
|
|
DONNATAL (BELLAD/PB) ELIXI 5ML
|
Facility
|
OP
|
$11.07
|
|
|
Service Code
|
NDC 50742066516
|
| Hospital Charge Code |
25003026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Aetna Commercial |
$8.52
|
| Rate for Payer: Anthem Medicaid |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.63
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.19
|
| Rate for Payer: First Health Commercial |
$10.52
|
| Rate for Payer: Humana Commercial |
$9.41
|
| Rate for Payer: Humana KY Medicaid |
$3.81
|
| Rate for Payer: Kentucky WC Medicaid |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.74
|
| Rate for Payer: Ohio Health Group HMO |
$8.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.43
|
| Rate for Payer: PHCS Commercial |
$10.63
|
| Rate for Payer: United Healthcare All Payer |
$9.74
|
|
|
DONNATAL (BELLAD/PB) TABL 1TAB
|
Facility
|
OP
|
$30.30
|
|
|
Service Code
|
NDC 59212042510
|
| Hospital Charge Code |
25003027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$29.09 |
| Rate for Payer: Aetna Commercial |
$23.33
|
| Rate for Payer: Anthem Medicaid |
$10.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.63
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cigna Commercial |
$25.15
|
| Rate for Payer: First Health Commercial |
$28.78
|
| Rate for Payer: Humana Commercial |
$25.76
|
| Rate for Payer: Humana KY Medicaid |
$10.42
|
| Rate for Payer: Kentucky WC Medicaid |
$10.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.66
|
| Rate for Payer: Ohio Health Group HMO |
$22.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.39
|
| Rate for Payer: PHCS Commercial |
$29.09
|
| Rate for Payer: United Healthcare All Payer |
$26.66
|
|
|
DONNATAL (BELLAD/PB) TABL 1TAB
|
Facility
|
IP
|
$30.30
|
|
|
Service Code
|
NDC 59212042510
|
| Hospital Charge Code |
25003027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$29.09 |
| Rate for Payer: Aetna Commercial |
$23.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.63
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cigna Commercial |
$25.15
|
| Rate for Payer: First Health Commercial |
$28.78
|
| Rate for Payer: Humana Commercial |
$25.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.66
|
| Rate for Payer: Ohio Health Group HMO |
$22.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.39
|
| Rate for Payer: PHCS Commercial |
$29.09
|
| Rate for Payer: United Healthcare All Payer |
$26.66
|
|
|
DOPAMINE 400 MG 10 ML VIAL
|
Facility
|
OP
|
$79.23
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.30 |
| Max. Negotiated Rate |
$76.06 |
| Rate for Payer: Aetna Commercial |
$61.01
|
| Rate for Payer: Anthem Medicaid |
$27.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.80
|
| Rate for Payer: Cash Price |
$39.62
|
| Rate for Payer: Cigna Commercial |
$65.76
|
| Rate for Payer: First Health Commercial |
$75.27
|
| Rate for Payer: Humana Commercial |
$67.35
|
| Rate for Payer: Humana KY Medicaid |
$27.25
|
| Rate for Payer: Kentucky WC Medicaid |
$27.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.72
|
| Rate for Payer: Ohio Health Group HMO |
$59.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.56
|
| Rate for Payer: PHCS Commercial |
$76.06
|
| Rate for Payer: United Healthcare All Payer |
$69.72
|
|
|
DOPAMINE 400 MG 10 ML VIAL
|
Facility
|
IP
|
$79.23
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.30 |
| Max. Negotiated Rate |
$76.06 |
| Rate for Payer: Aetna Commercial |
$61.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.80
|
| Rate for Payer: Cash Price |
$39.62
|
| Rate for Payer: Cigna Commercial |
$65.76
|
| Rate for Payer: First Health Commercial |
$75.27
|
| Rate for Payer: Humana Commercial |
$67.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.72
|
| Rate for Payer: Ohio Health Group HMO |
$59.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.56
|
| Rate for Payer: PHCS Commercial |
$76.06
|
| Rate for Payer: United Healthcare All Payer |
$69.72
|
|
|
DOPAMINE 800MG DEXTROSE 250ML
|
Facility
|
OP
|
$127.59
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.59 |
| Max. Negotiated Rate |
$122.49 |
| Rate for Payer: Aetna Commercial |
$98.24
|
| Rate for Payer: Anthem Medicaid |
$43.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.52
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cigna Commercial |
$105.90
|
| Rate for Payer: First Health Commercial |
$121.21
|
| Rate for Payer: Humana Commercial |
$108.45
|
| Rate for Payer: Humana KY Medicaid |
$43.88
|
| Rate for Payer: Kentucky WC Medicaid |
$44.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.28
|
| Rate for Payer: Ohio Health Group HMO |
$95.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.55
|
| Rate for Payer: PHCS Commercial |
$122.49
|
| Rate for Payer: United Healthcare All Payer |
$112.28
|
|
|
DOPAMINE 800MG DEXTROSE 250ML
|
Facility
|
IP
|
$127.59
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.59 |
| Max. Negotiated Rate |
$122.49 |
| Rate for Payer: Aetna Commercial |
$98.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.52
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cigna Commercial |
$105.90
|
| Rate for Payer: First Health Commercial |
$121.21
|
| Rate for Payer: Humana Commercial |
$108.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.28
|
| Rate for Payer: Ohio Health Group HMO |
$95.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.55
|
| Rate for Payer: PHCS Commercial |
$122.49
|
| Rate for Payer: United Healthcare All Payer |
$112.28
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
480P0110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Aetna Commercial |
$88.67
|
| Rate for Payer: Anthem Medicaid |
$83.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$220.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$152.50
|
| Rate for Payer: Healthspan PPO |
$83.34
|
| Rate for Payer: Humana Medicaid |
$83.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.89
|
| Rate for Payer: Molina Healthcare Passport |
$83.23
|
| Rate for Payer: Multiplan PHCS |
$132.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.00
|
| Rate for Payer: UHCCP Medicaid |
$77.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.06
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
OP
|
$846.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
48000110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$109.98 |
| Max. Negotiated Rate |
$812.16 |
| Rate for Payer: Aetna Commercial |
$651.42
|
| Rate for Payer: Anthem Medicaid |
$290.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$659.88
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cigna Commercial |
$702.18
|
| Rate for Payer: First Health Commercial |
$803.70
|
| Rate for Payer: Humana Commercial |
$719.10
|
| Rate for Payer: Humana KY Medicaid |
$290.94
|
| Rate for Payer: Kentucky WC Medicaid |
$293.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$693.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$624.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$296.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$744.48
|
| Rate for Payer: Ohio Health Group HMO |
$634.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$169.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.26
|
| Rate for Payer: PHCS Commercial |
$812.16
|
| Rate for Payer: United Healthcare All Payer |
$744.48
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
IP
|
$846.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
48000110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$109.98 |
| Max. Negotiated Rate |
$812.16 |
| Rate for Payer: Aetna Commercial |
$651.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$659.88
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cigna Commercial |
$702.18
|
| Rate for Payer: First Health Commercial |
$803.70
|
| Rate for Payer: Humana Commercial |
$719.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$693.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$624.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$744.48
|
| Rate for Payer: Ohio Health Group HMO |
$634.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$169.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.26
|
| Rate for Payer: PHCS Commercial |
$812.16
|
| Rate for Payer: United Healthcare All Payer |
$744.48
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Professional
|
Both
|
$846.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
48000110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$846.00 |
| Rate for Payer: Aetna Commercial |
$88.67
|
| Rate for Payer: Anthem Medicaid |
$83.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$846.00
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cigna Commercial |
$152.50
|
| Rate for Payer: Healthspan PPO |
$83.34
|
| Rate for Payer: Humana Medicaid |
$83.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.89
|
| Rate for Payer: Molina Healthcare Passport |
$83.23
|
| Rate for Payer: Multiplan PHCS |
$507.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$592.20
|
| Rate for Payer: UHCCP Medicaid |
$296.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.06
|
|
