|
DEXAMETHASONE 1MG [4MG/1ML]
|
Facility
|
OP
|
$15.95
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
636T0030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Anthem Medicaid |
$5.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.44
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna Commercial |
$13.24
|
| Rate for Payer: First Health Commercial |
$15.15
|
| Rate for Payer: Humana Commercial |
$13.56
|
| Rate for Payer: Humana KY Medicaid |
$5.49
|
| Rate for Payer: Kentucky WC Medicaid |
$5.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.04
|
| Rate for Payer: Ohio Health Group HMO |
$11.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.01
|
| Rate for Payer: PHCS Commercial |
$15.31
|
| Rate for Payer: United Healthcare All Payer |
$14.04
|
|
|
DEXAMETHASONE 1MG [4MG/1ML]
|
Facility
|
IP
|
$15.95
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
636T0030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.44
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna Commercial |
$13.24
|
| Rate for Payer: First Health Commercial |
$15.15
|
| Rate for Payer: Humana Commercial |
$13.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.04
|
| Rate for Payer: Ohio Health Group HMO |
$11.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.01
|
| Rate for Payer: PHCS Commercial |
$15.31
|
| Rate for Payer: United Healthcare All Payer |
$14.04
|
|
|
DEXAMETHASONE 1MG [4MG/1ML]
|
Facility
|
OP
|
$15.95
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
63600030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Anthem Medicaid |
$5.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.44
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna Commercial |
$13.24
|
| Rate for Payer: First Health Commercial |
$15.15
|
| Rate for Payer: Humana Commercial |
$13.56
|
| Rate for Payer: Humana KY Medicaid |
$5.49
|
| Rate for Payer: Kentucky WC Medicaid |
$5.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.04
|
| Rate for Payer: Ohio Health Group HMO |
$11.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.01
|
| Rate for Payer: PHCS Commercial |
$15.31
|
| Rate for Payer: United Healthcare All Payer |
$14.04
|
|
|
DEXAMETHASONE 1MG [4MG/1ML]
|
Facility
|
IP
|
$15.95
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
63600030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.44
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cigna Commercial |
$13.24
|
| Rate for Payer: First Health Commercial |
$15.15
|
| Rate for Payer: Humana Commercial |
$13.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.04
|
| Rate for Payer: Ohio Health Group HMO |
$11.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.01
|
| Rate for Payer: PHCS Commercial |
$15.31
|
| Rate for Payer: United Healthcare All Payer |
$14.04
|
|
|
DEXAMETHASONE 1MG [4MG/1ML]
|
Facility
|
OP
|
$63.78
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
25002014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.13 |
| Max. Negotiated Rate |
$61.23 |
| Rate for Payer: Aetna Commercial |
$49.11
|
| Rate for Payer: Anthem Medicaid |
$21.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.75
|
| Rate for Payer: Cash Price |
$31.89
|
| Rate for Payer: Cigna Commercial |
$52.94
|
| Rate for Payer: First Health Commercial |
$60.59
|
| Rate for Payer: Humana Commercial |
$54.21
|
| Rate for Payer: Humana KY Medicaid |
$21.93
|
| Rate for Payer: Kentucky WC Medicaid |
$22.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.13
|
| Rate for Payer: Ohio Health Group HMO |
$47.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.01
|
| Rate for Payer: PHCS Commercial |
$61.23
|
| Rate for Payer: United Healthcare All Payer |
$56.13
|
|
|
DEXAMETHASONE 1MG [4MG/1ML]
|
Facility
|
IP
|
$63.78
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
25002014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.13 |
| Max. Negotiated Rate |
$61.23 |
| Rate for Payer: Aetna Commercial |
$49.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.75
|
| Rate for Payer: Cash Price |
$31.89
|
| Rate for Payer: Cigna Commercial |
$52.94
|
| Rate for Payer: First Health Commercial |
$60.59
|
| Rate for Payer: Humana Commercial |
$54.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.13
|
| Rate for Payer: Ohio Health Group HMO |
$47.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.01
|
| Rate for Payer: PHCS Commercial |
$61.23
|
| Rate for Payer: United Healthcare All Payer |
$56.13
|
|
|
DEXILANT 60 MG CAPSULE
|
Facility
|
IP
|
$27.28
|
|
|
Service Code
|
NDC 64764017590
|
| Hospital Charge Code |
25000548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Aetna Commercial |
$21.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.28
|
| Rate for Payer: Cash Price |
$13.64
|
| Rate for Payer: Cigna Commercial |
$22.64
|
| Rate for Payer: First Health Commercial |
$25.92
|
| Rate for Payer: Humana Commercial |
$23.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.01
|
| Rate for Payer: Ohio Health Group HMO |
$20.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.82
|
| Rate for Payer: PHCS Commercial |
$26.19
|
| Rate for Payer: United Healthcare All Payer |
$24.01
|
|
|
DEXILANT 60 MG CAPSULE
|
Facility
|
OP
|
$27.28
|
|
|
Service Code
|
NDC 64764017590
|
| Hospital Charge Code |
25000548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Aetna Commercial |
$21.01
|
| Rate for Payer: Anthem Medicaid |
$9.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.28
|
| Rate for Payer: Cash Price |
$13.64
|
| Rate for Payer: Cigna Commercial |
$22.64
|
| Rate for Payer: First Health Commercial |
$25.92
|
| Rate for Payer: Humana Commercial |
$23.19
|
| Rate for Payer: Humana KY Medicaid |
$9.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.01
|
| Rate for Payer: Ohio Health Group HMO |
$20.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.82
|
| Rate for Payer: PHCS Commercial |
$26.19
|
| Rate for Payer: United Healthcare All Payer |
$24.01
|
|
|
DEXMEDETOMIDINE 80mcg/20mL SDV
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004185
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem Medicaid |
$62.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.96
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Humana KY Medicaid |
$62.59
|
| Rate for Payer: Kentucky WC Medicaid |
$63.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.58
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
|
DEXMEDETOMIDINE 80mcg/20mL SDV
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004185
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.96
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.58
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
|
DEXTROS5%NACL4.45%KCL20MEQ1000
|
Facility
|
OP
|
$114.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002992
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$34.22 |
| Max. Negotiated Rate |
$109.51 |
| Rate for Payer: Aetna Commercial |
$87.83
|
| Rate for Payer: Anthem Medicaid |
$39.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.97
|
| Rate for Payer: Cash Price |
$57.03
|
| Rate for Payer: Cigna Commercial |
$94.68
|
| Rate for Payer: First Health Commercial |
$108.37
|
| Rate for Payer: Humana Commercial |
$96.96
|
| Rate for Payer: Humana KY Medicaid |
$39.23
|
| Rate for Payer: Kentucky WC Medicaid |
$39.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.38
|
| Rate for Payer: Ohio Health Group HMO |
$85.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.71
|
| Rate for Payer: PHCS Commercial |
$109.51
|
| Rate for Payer: United Healthcare All Payer |
$100.38
|
|
|
DEXTROS5%NACL4.45%KCL20MEQ1000
|
Facility
|
IP
|
$114.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002992
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$34.22 |
| Max. Negotiated Rate |
$109.51 |
| Rate for Payer: Aetna Commercial |
$87.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.97
|
| Rate for Payer: Cash Price |
$57.03
|
| Rate for Payer: Cigna Commercial |
$94.68
|
| Rate for Payer: First Health Commercial |
$108.37
|
| Rate for Payer: Humana Commercial |
$96.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.38
|
| Rate for Payer: Ohio Health Group HMO |
$85.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.71
|
| Rate for Payer: PHCS Commercial |
$109.51
|
| Rate for Payer: United Healthcare All Payer |
$100.38
|
|
|
DEXTROSE 10% 25GM/250ML BAG
|
Facility
|
OP
|
$112.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004254
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$107.76 |
| Rate for Payer: Aetna Commercial |
$86.43
|
| Rate for Payer: Anthem Medicaid |
$38.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.56
|
| Rate for Payer: Cash Price |
$56.12
|
| Rate for Payer: Cigna Commercial |
$93.17
|
| Rate for Payer: First Health Commercial |
$106.64
|
| Rate for Payer: Humana Commercial |
$95.41
|
| Rate for Payer: Humana KY Medicaid |
$38.60
|
| Rate for Payer: Kentucky WC Medicaid |
$39.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.78
|
| Rate for Payer: Ohio Health Group HMO |
$84.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.45
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
DEXTROSE 10% 25GM/250ML BAG
|
Facility
|
IP
|
$112.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004254
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$107.76 |
| Rate for Payer: Aetna Commercial |
$86.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.56
|
| Rate for Payer: Cash Price |
$56.12
|
| Rate for Payer: Cigna Commercial |
$93.17
|
| Rate for Payer: First Health Commercial |
$106.64
|
| Rate for Payer: Humana Commercial |
$95.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.78
|
| Rate for Payer: Ohio Health Group HMO |
$84.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.45
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
DEXTROSE 10% 500ML
|
Facility
|
IP
|
$94.98
|
|
|
Service Code
|
NDC 990793003
|
| Hospital Charge Code |
25004235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Aetna Commercial |
$73.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.08
|
| Rate for Payer: Cash Price |
$47.49
|
| Rate for Payer: Cigna Commercial |
$78.83
|
| Rate for Payer: First Health Commercial |
$90.23
|
| Rate for Payer: Humana Commercial |
$80.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.58
|
| Rate for Payer: Ohio Health Group HMO |
$71.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.54
|
| Rate for Payer: PHCS Commercial |
$91.18
|
| Rate for Payer: United Healthcare All Payer |
$83.58
|
|
|
DEXTROSE 10% 500ML
|
Facility
|
OP
|
$94.98
|
|
|
Service Code
|
NDC 990793003
|
| Hospital Charge Code |
25004235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Aetna Commercial |
$73.13
|
| Rate for Payer: Anthem Medicaid |
$32.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.08
|
| Rate for Payer: Cash Price |
$47.49
|
| Rate for Payer: Cigna Commercial |
$78.83
|
| Rate for Payer: First Health Commercial |
$90.23
|
| Rate for Payer: Humana Commercial |
$80.73
|
| Rate for Payer: Humana KY Medicaid |
$32.66
|
| Rate for Payer: Kentucky WC Medicaid |
$33.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.58
|
| Rate for Payer: Ohio Health Group HMO |
$71.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.54
|
| Rate for Payer: PHCS Commercial |
$91.18
|
| Rate for Payer: United Healthcare All Payer |
$83.58
|
|
|
DEXTROSE 10% (FS) 1000ML
|
Facility
|
OP
|
$5.25
|
|
|
Service Code
|
NDC 990793009
|
| Hospital Charge Code |
25002993
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$1.81
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: Cigna Commercial |
$4.36
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: First Health Commercial |
$4.99
|
| Rate for Payer: Humana Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$1.81
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.03
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: PHCS Commercial |
$5.04
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
| Rate for Payer: United Healthcare All Payer |
$4.62
|
|
|
DEXTROSE 10% (FS) 1000ML
|
Facility
|
IP
|
$5.25
|
|
|
Service Code
|
NDC 990793009
|
| Hospital Charge Code |
25002993
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$4.36
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: First Health Commercial |
$4.99
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana Commercial |
$4.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.62
|
| Rate for Payer: PHCS Commercial |
$5.04
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 25% 2.5GM (INFANT)SYR
|
Facility
|
OP
|
$37.59
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
25002995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$36.09 |
| Rate for Payer: Aetna Commercial |
$28.94
|
| Rate for Payer: Anthem Medicaid |
$12.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.32
|
| Rate for Payer: Cash Price |
$18.80
|
| Rate for Payer: Cigna Commercial |
$31.20
|
| Rate for Payer: First Health Commercial |
$35.71
|
| Rate for Payer: Humana Commercial |
$31.95
|
| Rate for Payer: Humana KY Medicaid |
$12.93
|
| Rate for Payer: Kentucky WC Medicaid |
$13.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.08
|
| Rate for Payer: Ohio Health Group HMO |
$28.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.94
|
| Rate for Payer: PHCS Commercial |
$36.09
|
| Rate for Payer: United Healthcare All Payer |
$33.08
|
|
|
DEXTROSE 25% 2.5GM (INFANT)SYR
|
Facility
|
IP
|
$37.59
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
25002995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$36.09 |
| Rate for Payer: Aetna Commercial |
$28.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.32
|
| Rate for Payer: Cash Price |
$18.80
|
| Rate for Payer: Cigna Commercial |
$31.20
|
| Rate for Payer: First Health Commercial |
$35.71
|
| Rate for Payer: Humana Commercial |
$31.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.08
|
| Rate for Payer: Ohio Health Group HMO |
$28.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.94
|
| Rate for Payer: PHCS Commercial |
$36.09
|
| Rate for Payer: United Healthcare All Payer |
$33.08
|
|
|
DEXTROSE 25GM/50ML VL
|
Facility
|
IP
|
$112.22
|
|
|
Service Code
|
NDC 409664802
|
| Hospital Charge Code |
25002996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$86.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.53
|
| Rate for Payer: Cash Price |
$56.11
|
| Rate for Payer: Cigna Commercial |
$93.14
|
| Rate for Payer: First Health Commercial |
$106.61
|
| Rate for Payer: Humana Commercial |
$95.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.75
|
| Rate for Payer: Ohio Health Group HMO |
$84.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.43
|
| Rate for Payer: PHCS Commercial |
$107.73
|
| Rate for Payer: United Healthcare All Payer |
$98.75
|
|
|
DEXTROSE 25GM/50ML VL
|
Facility
|
OP
|
$112.22
|
|
|
Service Code
|
NDC 409664802
|
| Hospital Charge Code |
25002996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$86.41
|
| Rate for Payer: Anthem Medicaid |
$38.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.53
|
| Rate for Payer: Cash Price |
$56.11
|
| Rate for Payer: Cigna Commercial |
$93.14
|
| Rate for Payer: First Health Commercial |
$106.61
|
| Rate for Payer: Humana Commercial |
$95.39
|
| Rate for Payer: Humana KY Medicaid |
$38.59
|
| Rate for Payer: Kentucky WC Medicaid |
$38.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.75
|
| Rate for Payer: Ohio Health Group HMO |
$84.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.43
|
| Rate for Payer: PHCS Commercial |
$107.73
|
| Rate for Payer: United Healthcare All Payer |
$98.75
|
|
|
DEXTROSE 50% (25GM/50ML) SYR
|
Facility
|
OP
|
$127.24
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003016
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$38.17 |
| Max. Negotiated Rate |
$122.15 |
| Rate for Payer: Aetna Commercial |
$97.97
|
| Rate for Payer: Anthem Medicaid |
$43.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.25
|
| Rate for Payer: Cash Price |
$63.62
|
| Rate for Payer: Cigna Commercial |
$105.61
|
| Rate for Payer: First Health Commercial |
$120.88
|
| Rate for Payer: Humana Commercial |
$108.15
|
| Rate for Payer: Humana KY Medicaid |
$43.76
|
| Rate for Payer: Kentucky WC Medicaid |
$44.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.97
|
| Rate for Payer: Ohio Health Group HMO |
$95.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.80
|
| Rate for Payer: PHCS Commercial |
$122.15
|
| Rate for Payer: United Healthcare All Payer |
$111.97
|
|
|
DEXTROSE 50% (25GM/50ML) SYR
|
Facility
|
IP
|
$127.24
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003016
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$38.17 |
| Max. Negotiated Rate |
$122.15 |
| Rate for Payer: Aetna Commercial |
$97.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.25
|
| Rate for Payer: Cash Price |
$63.62
|
| Rate for Payer: Cigna Commercial |
$105.61
|
| Rate for Payer: First Health Commercial |
$120.88
|
| Rate for Payer: Humana Commercial |
$108.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.97
|
| Rate for Payer: Ohio Health Group HMO |
$95.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.80
|
| Rate for Payer: PHCS Commercial |
$122.15
|
| Rate for Payer: United Healthcare All Payer |
$111.97
|
|
|
DEXTROSE 5%/0.2% NACL (F 500ML
|
Facility
|
IP
|
$95.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003010
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$28.66 |
| Max. Negotiated Rate |
$91.72 |
| Rate for Payer: Aetna Commercial |
$73.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.52
|
| Rate for Payer: Cash Price |
$47.77
|
| Rate for Payer: Cigna Commercial |
$79.30
|
| Rate for Payer: First Health Commercial |
$90.76
|
| Rate for Payer: Humana Commercial |
$81.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.08
|
| Rate for Payer: Ohio Health Group HMO |
$71.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.92
|
| Rate for Payer: PHCS Commercial |
$91.72
|
| Rate for Payer: United Healthcare All Payer |
$84.08
|
|
