|
DERMA SMOOTHE FS OIL
|
Facility
|
IP
|
$4.13
|
|
|
Service Code
|
NDC 68791010204
|
| Hospital Charge Code |
25000539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cigna Commercial |
$3.43
|
| Rate for Payer: First Health Commercial |
$3.92
|
| Rate for Payer: Humana Commercial |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.63
|
| Rate for Payer: Ohio Health Group HMO |
$3.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.85
|
| Rate for Payer: PHCS Commercial |
$3.96
|
| Rate for Payer: United Healthcare All Payer |
$3.63
|
|
|
DERMATOPHAGOLDEPTERONYSINUSIGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000678
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DERMATOPHAGOLDEPTERONYSINUSIGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000678
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DERMATOPHAGOLDES FARINAE IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000947
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DERMATOPHAGOLDES FARINAE IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000947
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DERMOPLAST(BENZOCAINE) AER 2OZ
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 16864068003
|
| Hospital Charge Code |
25002985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna Commercial |
$0.06
|
| Rate for Payer: Anthem Medicaid |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.07
|
| Rate for Payer: First Health Commercial |
$0.08
|
| Rate for Payer: Humana Commercial |
$0.07
|
| Rate for Payer: Humana KY Medicaid |
$0.03
|
| Rate for Payer: Kentucky WC Medicaid |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.07
|
| Rate for Payer: Ohio Health Group HMO |
$0.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Payer |
$0.07
|
|
|
DERMOPLAST(BENZOCAINE) AER 2OZ
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 16864068003
|
| Hospital Charge Code |
25002985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna Commercial |
$0.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.07
|
| Rate for Payer: First Health Commercial |
$0.08
|
| Rate for Payer: Humana Commercial |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.07
|
| Rate for Payer: Ohio Health Group HMO |
$0.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Payer |
$0.07
|
|
|
DESFERAL [500 MG] 500MG VIAL
|
Facility
|
OP
|
$121.76
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
25002002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.53 |
| Max. Negotiated Rate |
$116.89 |
| Rate for Payer: Aetna Commercial |
$93.76
|
| Rate for Payer: Aetna Commercial |
$61.94
|
| Rate for Payer: Anthem Medicaid |
$41.87
|
| Rate for Payer: Anthem Medicaid |
$27.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.74
|
| Rate for Payer: Cash Price |
$60.88
|
| Rate for Payer: Cash Price |
$40.22
|
| Rate for Payer: Cigna Commercial |
$66.77
|
| Rate for Payer: Cigna Commercial |
$101.06
|
| Rate for Payer: First Health Commercial |
$76.42
|
| Rate for Payer: First Health Commercial |
$115.67
|
| Rate for Payer: Humana Commercial |
$103.50
|
| Rate for Payer: Humana Commercial |
$68.37
|
| Rate for Payer: Humana KY Medicaid |
$41.87
|
| Rate for Payer: Humana KY Medicaid |
$27.66
|
| Rate for Payer: Kentucky WC Medicaid |
$27.94
|
| Rate for Payer: Kentucky WC Medicaid |
$42.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.79
|
| Rate for Payer: Ohio Health Group HMO |
$91.32
|
| Rate for Payer: Ohio Health Group HMO |
$60.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.50
|
| Rate for Payer: PHCS Commercial |
$77.22
|
| Rate for Payer: PHCS Commercial |
$116.89
|
| Rate for Payer: United Healthcare All Payer |
$70.79
|
| Rate for Payer: United Healthcare All Payer |
$107.15
|
|
|
DESFERAL [500 MG] 500MG VIAL
|
Facility
|
IP
|
$121.76
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
25002002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.53 |
| Max. Negotiated Rate |
$116.89 |
| Rate for Payer: Aetna Commercial |
$93.76
|
| Rate for Payer: Aetna Commercial |
$61.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.74
|
| Rate for Payer: Cash Price |
$60.88
|
| Rate for Payer: Cash Price |
$40.22
|
| Rate for Payer: Cigna Commercial |
$101.06
|
| Rate for Payer: Cigna Commercial |
$66.77
|
| Rate for Payer: First Health Commercial |
$76.42
|
| Rate for Payer: First Health Commercial |
$115.67
|
| Rate for Payer: Humana Commercial |
$68.37
|
| Rate for Payer: Humana Commercial |
$103.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.79
|
| Rate for Payer: Ohio Health Group HMO |
$91.32
|
| Rate for Payer: Ohio Health Group HMO |
$60.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.01
|
| Rate for Payer: PHCS Commercial |
$116.89
|
| Rate for Payer: PHCS Commercial |
$77.22
|
| Rate for Payer: United Healthcare All Payer |
$107.15
|
| Rate for Payer: United Healthcare All Payer |
$70.79
|
|
|
DESFERAL IM 500MG VIAL
|
Facility
|
OP
|
$80.44
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
25002001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$77.22 |
| Rate for Payer: Aetna Commercial |
$61.94
|
| Rate for Payer: Anthem Medicaid |
$27.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.74
|
| Rate for Payer: Cash Price |
$40.22
|
| Rate for Payer: Cigna Commercial |
$66.77
|
| Rate for Payer: First Health Commercial |
$76.42
|
| Rate for Payer: Humana Commercial |
$68.37
|
| Rate for Payer: Humana KY Medicaid |
$27.66
|
| Rate for Payer: Kentucky WC Medicaid |
$27.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.79
|
| Rate for Payer: Ohio Health Group HMO |
$60.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.50
|
| Rate for Payer: PHCS Commercial |
$77.22
|
| Rate for Payer: United Healthcare All Payer |
$70.79
|
|
|
DESFERAL IM 500MG VIAL
|
Facility
|
IP
|
$80.44
|
|
|
Service Code
|
HCPCS J0895
|
| Hospital Charge Code |
25002001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$77.22 |
| Rate for Payer: Aetna Commercial |
$61.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.74
|
| Rate for Payer: Cash Price |
$40.22
|
| Rate for Payer: Cigna Commercial |
$66.77
|
| Rate for Payer: First Health Commercial |
$76.42
|
| Rate for Payer: Humana Commercial |
$68.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.79
|
| Rate for Payer: Ohio Health Group HMO |
$60.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.50
|
| Rate for Payer: PHCS Commercial |
$77.22
|
| Rate for Payer: United Healthcare All Payer |
$70.79
|
|
|
DESIGN MLC DEVICE FOR IMRT
|
Professional
|
Both
|
$2,278.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
33300018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$277.05 |
| Max. Negotiated Rate |
$1,366.80 |
| Rate for Payer: Aetna Commercial |
$728.87
|
| Rate for Payer: Ambetter Exchange |
$433.84
|
| Rate for Payer: Anthem Medicaid |
$350.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$433.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$433.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$520.61
|
| Rate for Payer: Cash Price |
$1,139.00
|
| Rate for Payer: Cash Price |
$1,139.00
|
| Rate for Payer: Cigna Commercial |
$747.61
|
| Rate for Payer: Healthspan PPO |
$482.64
|
| Rate for Payer: Humana Medicaid |
$350.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$277.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$433.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$433.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$357.93
|
| Rate for Payer: Molina Healthcare Passport |
$350.91
|
| Rate for Payer: Multiplan PHCS |
$1,366.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$563.99
|
| Rate for Payer: UHCCP Medicaid |
$797.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$354.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$433.84
|
|
|
DESIGN MLC DEVICE FOR IMRT
|
Facility
|
IP
|
$2,278.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
33300018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$683.40 |
| Max. Negotiated Rate |
$2,186.88 |
| Rate for Payer: Aetna Commercial |
$1,754.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,776.84
|
| Rate for Payer: Cash Price |
$1,139.00
|
| Rate for Payer: Cigna Commercial |
$1,890.74
|
| Rate for Payer: First Health Commercial |
$2,164.10
|
| Rate for Payer: Humana Commercial |
$1,936.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,867.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,681.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$683.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,004.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,708.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,822.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,981.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,571.82
|
| Rate for Payer: PHCS Commercial |
$2,186.88
|
| Rate for Payer: United Healthcare All Payer |
$2,004.64
|
|
|
DESIGN MLC DEVICE FOR IMRT
|
Facility
|
OP
|
$2,278.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
33300018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$338.24 |
| Max. Negotiated Rate |
$2,186.88 |
| Rate for Payer: Aetna Commercial |
$1,754.06
|
| Rate for Payer: Anthem Medicaid |
$783.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$338.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,776.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$473.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$456.62
|
| Rate for Payer: Cash Price |
$1,139.00
|
| Rate for Payer: Cash Price |
$1,139.00
|
| Rate for Payer: Cigna Commercial |
$1,890.74
|
| Rate for Payer: First Health Commercial |
$2,164.10
|
| Rate for Payer: Humana Commercial |
$1,936.30
|
| Rate for Payer: Humana KY Medicaid |
$783.40
|
| Rate for Payer: Humana Medicare Advantage |
$338.24
|
| Rate for Payer: Kentucky WC Medicaid |
$791.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,867.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,681.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$799.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,004.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,708.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,822.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,981.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,571.82
|
| Rate for Payer: PHCS Commercial |
$2,186.88
|
| Rate for Payer: United Healthcare All Payer |
$2,004.64
|
|
|
DESIGN MLC DEVICE FOR IMRT(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
333P0018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$747.61 |
| Rate for Payer: Aetna Commercial |
$728.87
|
| Rate for Payer: Ambetter Exchange |
$433.84
|
| Rate for Payer: Anthem Medicaid |
$350.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$433.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$433.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$520.61
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$747.61
|
| Rate for Payer: Healthspan PPO |
$482.64
|
| Rate for Payer: Humana Medicaid |
$350.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$277.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$433.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$433.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$357.93
|
| Rate for Payer: Molina Healthcare Passport |
$350.91
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$563.99
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$354.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$433.84
|
|
|
DESIGN MLC DEVICE FOR IMRT(T
|
Facility
|
IP
|
$1,878.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
333T0018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$563.40 |
| Max. Negotiated Rate |
$1,802.88 |
| Rate for Payer: Aetna Commercial |
$1,446.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,464.84
|
| Rate for Payer: Cash Price |
$939.00
|
| Rate for Payer: Cigna Commercial |
$1,558.74
|
| Rate for Payer: First Health Commercial |
$1,784.10
|
| Rate for Payer: Humana Commercial |
$1,596.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,539.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,385.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,652.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,408.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,502.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,633.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.82
|
| Rate for Payer: PHCS Commercial |
$1,802.88
|
| Rate for Payer: United Healthcare All Payer |
$1,652.64
|
|
|
DESIGN MLC DEVICE FOR IMRT(T
|
Facility
|
OP
|
$1,878.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
333T0018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$338.24 |
| Max. Negotiated Rate |
$1,802.88 |
| Rate for Payer: Aetna Commercial |
$1,446.06
|
| Rate for Payer: Anthem Medicaid |
$645.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$338.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,464.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$473.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$456.62
|
| Rate for Payer: Cash Price |
$939.00
|
| Rate for Payer: Cash Price |
$939.00
|
| Rate for Payer: Cigna Commercial |
$1,558.74
|
| Rate for Payer: First Health Commercial |
$1,784.10
|
| Rate for Payer: Humana Commercial |
$1,596.30
|
| Rate for Payer: Humana KY Medicaid |
$645.84
|
| Rate for Payer: Humana Medicare Advantage |
$338.24
|
| Rate for Payer: Kentucky WC Medicaid |
$652.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,539.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,385.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$658.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,652.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,408.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,502.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,633.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.82
|
| Rate for Payer: PHCS Commercial |
$1,802.88
|
| Rate for Payer: United Healthcare All Payer |
$1,652.64
|
|
|
DESIPRAMINE 10MG TABLET
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 69238105301
|
| Hospital Charge Code |
25002987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
DESIPRAMINE 10MG TABLET
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 69238105301
|
| Hospital Charge Code |
25002987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
DESIPRAMINE 25MG TABLET
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 50742011301
|
| Hospital Charge Code |
25000540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
DESIPRAMINE 25MG TABLET
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 50742011301
|
| Hospital Charge Code |
25000540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
DESITIN OINT 2 OZ.
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 74300000070
|
| Hospital Charge Code |
25000541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
DESITIN OINT 2 OZ.
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 74300000070
|
| Hospital Charge Code |
25000541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
DES LESIOPALAT ULVULA CRYOCHM
|
Facility
|
OP
|
$3,912.00
|
|
|
Service Code
|
HCPCS 42160
|
| Hospital Charge Code |
45000257
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,345.34 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$3,012.24
|
| Rate for Payer: Anthem Medicaid |
$1,345.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$1,956.00
|
| Rate for Payer: Cash Price |
$1,956.00
|
| Rate for Payer: Cigna Commercial |
$3,246.96
|
| Rate for Payer: First Health Commercial |
$3,716.40
|
| Rate for Payer: Humana Commercial |
$3,325.20
|
| Rate for Payer: Humana KY Medicaid |
$1,345.34
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,359.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,207.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,372.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,129.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,403.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,699.28
|
| Rate for Payer: PHCS Commercial |
$3,755.52
|
| Rate for Payer: United Healthcare All Payer |
$3,442.56
|
|
|
DES LESIOPALAT ULVULA CRYOCHM
|
Facility
|
OP
|
$3,752.00
|
|
|
Service Code
|
HCPCS 42160
|
| Hospital Charge Code |
76101675
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,290.31 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$2,889.04
|
| Rate for Payer: Anthem Medicaid |
$1,290.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,926.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$1,876.00
|
| Rate for Payer: Cash Price |
$1,876.00
|
| Rate for Payer: Cigna Commercial |
$3,114.16
|
| Rate for Payer: First Health Commercial |
$3,564.40
|
| Rate for Payer: Humana Commercial |
$3,189.20
|
| Rate for Payer: Humana KY Medicaid |
$1,290.31
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,303.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,076.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,768.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,316.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,301.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,814.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,001.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,264.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,588.88
|
| Rate for Payer: PHCS Commercial |
$3,601.92
|
| Rate for Payer: United Healthcare All Payer |
$3,301.76
|
|
