|
DEXTROSE 5%/0.2% NACL (F 500ML
|
Facility
|
OP
|
$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 Medicaid |
$32.86
|
| 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: Humana KY Medicaid |
$32.86
|
| Rate for Payer: Kentucky WC Medicaid |
$33.19
|
| 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: Molina Healthcare Medicaid |
$33.52
|
| 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
|
|
|
DEXTROSE 5%/0.45% NACL 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003011
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.45% NACL 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003011
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/0.45% NACL ( 500ML
|
Facility
|
OP
|
$94.71
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003012
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$28.41 |
| Max. Negotiated Rate |
$90.92 |
| Rate for Payer: Aetna Commercial |
$72.93
|
| Rate for Payer: Anthem Medicaid |
$32.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.87
|
| Rate for Payer: Cash Price |
$47.35
|
| Rate for Payer: Cigna Commercial |
$78.61
|
| Rate for Payer: First Health Commercial |
$89.97
|
| Rate for Payer: Humana Commercial |
$80.50
|
| Rate for Payer: Humana KY Medicaid |
$32.57
|
| Rate for Payer: Kentucky WC Medicaid |
$32.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.34
|
| Rate for Payer: Ohio Health Group HMO |
$71.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.35
|
| Rate for Payer: PHCS Commercial |
$90.92
|
| Rate for Payer: United Healthcare All Payer |
$83.34
|
|
|
DEXTROSE 5%/0.45% NACL ( 500ML
|
Facility
|
IP
|
$94.71
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003012
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$28.41 |
| Max. Negotiated Rate |
$90.92 |
| Rate for Payer: Aetna Commercial |
$72.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.87
|
| Rate for Payer: Cash Price |
$47.35
|
| Rate for Payer: Cigna Commercial |
$78.61
|
| Rate for Payer: First Health Commercial |
$89.97
|
| Rate for Payer: Humana Commercial |
$80.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.34
|
| Rate for Payer: Ohio Health Group HMO |
$71.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.35
|
| Rate for Payer: PHCS Commercial |
$90.92
|
| Rate for Payer: United Healthcare All Payer |
$83.34
|
|
|
DEXTROSE 5%/0.9% NACL (F 500ML
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
DEXTROSE 5%/0.9% NACL (F 500ML
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$31.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$31.98
|
| Rate for Payer: Kentucky WC Medicaid |
$32.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
DEXTROSE 5% (FS) 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
25002997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (FS) 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
25002997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% GLASS (IVPB) 107ML
|
Facility
|
IP
|
$66.47
|
|
|
Service Code
|
NDC 264151032
|
| Hospital Charge Code |
25003005
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.94 |
| Max. Negotiated Rate |
$63.81 |
| Rate for Payer: Aetna Commercial |
$51.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.85
|
| Rate for Payer: Cash Price |
$33.24
|
| Rate for Payer: Cigna Commercial |
$55.17
|
| Rate for Payer: First Health Commercial |
$63.15
|
| Rate for Payer: Humana Commercial |
$56.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.49
|
| Rate for Payer: Ohio Health Group HMO |
$49.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.86
|
| Rate for Payer: PHCS Commercial |
$63.81
|
| Rate for Payer: United Healthcare All Payer |
$58.49
|
|
|
DEXTROSE 5% GLASS (IVPB) 107ML
|
Facility
|
OP
|
$66.47
|
|
|
Service Code
|
NDC 264151032
|
| Hospital Charge Code |
25003005
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.94 |
| Max. Negotiated Rate |
$63.81 |
| Rate for Payer: Aetna Commercial |
$51.18
|
| Rate for Payer: Anthem Medicaid |
$22.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.85
|
| Rate for Payer: Cash Price |
$33.24
|
| Rate for Payer: Cigna Commercial |
$55.17
|
| Rate for Payer: First Health Commercial |
$63.15
|
| Rate for Payer: Humana Commercial |
$56.50
|
| Rate for Payer: Humana KY Medicaid |
$22.86
|
| Rate for Payer: Kentucky WC Medicaid |
$23.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.49
|
| Rate for Payer: Ohio Health Group HMO |
$49.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.86
|
| Rate for Payer: PHCS Commercial |
$63.81
|
| Rate for Payer: United Healthcare All Payer |
$58.49
|
|
|
DEXTROSE 5% (IVPB) 280ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (IVPB) 280ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (IVPB) 500ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (IVPB) 500ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
25002999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/LACTATED RI 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/LACTATED RI 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/LACTATED RIN 500ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5%/LACTATED RIN 500ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
25003015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| 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: Molina Healthcare Benefit Exchange |
$28.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.40
|
| 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: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
DEXTROSE 5% (LVP) 100ML
|
Facility
|
IP
|
$92.08
|
|
|
Service Code
|
NDC 990792337
|
| Hospital Charge Code |
25003002
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$88.40 |
| Rate for Payer: Aetna Commercial |
$70.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.82
|
| Rate for Payer: Cash Price |
$46.04
|
| Rate for Payer: Cigna Commercial |
$76.43
|
| Rate for Payer: First Health Commercial |
$87.48
|
| Rate for Payer: Humana Commercial |
$78.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.03
|
| Rate for Payer: Ohio Health Group HMO |
$69.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.54
|
| Rate for Payer: PHCS Commercial |
$88.40
|
| Rate for Payer: United Healthcare All Payer |
$81.03
|
|
|
DEXTROSE 5% (LVP) 100ML
|
Facility
|
OP
|
$92.08
|
|
|
Service Code
|
NDC 990792337
|
| Hospital Charge Code |
25003002
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$27.62 |
| Max. Negotiated Rate |
$88.40 |
| Rate for Payer: Aetna Commercial |
$70.90
|
| Rate for Payer: Anthem Medicaid |
$31.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.82
|
| Rate for Payer: Cash Price |
$46.04
|
| Rate for Payer: Cigna Commercial |
$76.43
|
| Rate for Payer: First Health Commercial |
$87.48
|
| Rate for Payer: Humana Commercial |
$78.27
|
| Rate for Payer: Humana KY Medicaid |
$31.67
|
| Rate for Payer: Kentucky WC Medicaid |
$31.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.03
|
| Rate for Payer: Ohio Health Group HMO |
$69.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.54
|
| Rate for Payer: PHCS Commercial |
$88.40
|
| Rate for Payer: United Healthcare All Payer |
$81.03
|
|
|
DEXTROSE 5% (LVP) 25ML
|
Facility
|
OP
|
$73.39
|
|
|
Service Code
|
NDC 990792320
|
| Hospital Charge Code |
25003000
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.02 |
| Max. Negotiated Rate |
$70.45 |
| Rate for Payer: Aetna Commercial |
$56.51
|
| Rate for Payer: Anthem Medicaid |
$25.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.24
|
| Rate for Payer: Cash Price |
$36.70
|
| Rate for Payer: Cigna Commercial |
$60.91
|
| Rate for Payer: First Health Commercial |
$69.72
|
| Rate for Payer: Humana Commercial |
$62.38
|
| Rate for Payer: Humana KY Medicaid |
$25.24
|
| Rate for Payer: Kentucky WC Medicaid |
$25.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.58
|
| Rate for Payer: Ohio Health Group HMO |
$55.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.64
|
| Rate for Payer: PHCS Commercial |
$70.45
|
| Rate for Payer: United Healthcare All Payer |
$64.58
|
|
|
DEXTROSE 5% (LVP) 25ML
|
Facility
|
IP
|
$73.39
|
|
|
Service Code
|
NDC 990792320
|
| Hospital Charge Code |
25003000
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.02 |
| Max. Negotiated Rate |
$70.45 |
| Rate for Payer: Aetna Commercial |
$56.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.24
|
| Rate for Payer: Cash Price |
$36.70
|
| Rate for Payer: Cigna Commercial |
$60.91
|
| Rate for Payer: First Health Commercial |
$69.72
|
| Rate for Payer: Humana Commercial |
$62.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.58
|
| Rate for Payer: Ohio Health Group HMO |
$55.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.64
|
| Rate for Payer: PHCS Commercial |
$70.45
|
| Rate for Payer: United Healthcare All Payer |
$64.58
|
|
|
DEXTROSE 5% (LVP) 50ML
|
Facility
|
OP
|
$78.98
|
|
|
Service Code
|
NDC 990792336
|
| Hospital Charge Code |
25003001
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$75.82 |
| Rate for Payer: Aetna Commercial |
$60.81
|
| Rate for Payer: Anthem Medicaid |
$27.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.60
|
| Rate for Payer: Cash Price |
$39.49
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: First Health Commercial |
$75.03
|
| Rate for Payer: Humana Commercial |
$67.13
|
| Rate for Payer: Humana KY Medicaid |
$27.16
|
| Rate for Payer: Kentucky WC Medicaid |
$27.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.50
|
| Rate for Payer: Ohio Health Group HMO |
$59.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.50
|
| Rate for Payer: PHCS Commercial |
$75.82
|
| Rate for Payer: United Healthcare All Payer |
$69.50
|
|
|
DEXTROSE 5% (LVP) 50ML
|
Facility
|
IP
|
$78.98
|
|
|
Service Code
|
NDC 990792336
|
| Hospital Charge Code |
25003001
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$75.82 |
| Rate for Payer: Aetna Commercial |
$60.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.60
|
| Rate for Payer: Cash Price |
$39.49
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: First Health Commercial |
$75.03
|
| Rate for Payer: Humana Commercial |
$67.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.50
|
| Rate for Payer: Ohio Health Group HMO |
$59.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.50
|
| Rate for Payer: PHCS Commercial |
$75.82
|
| Rate for Payer: United Healthcare All Payer |
$69.50
|
|
