|
DEXTROSE 5% SINGLES 1 5%/100ML
|
Facility
|
OP
|
$79.79
|
|
|
Service Code
|
NDC 990792323
|
| Hospital Charge Code |
25003007
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$76.60 |
| Rate for Payer: Aetna Commercial |
$61.44
|
| Rate for Payer: Anthem Medicaid |
$27.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.24
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$66.23
|
| Rate for Payer: First Health Commercial |
$75.80
|
| Rate for Payer: Humana Commercial |
$67.82
|
| Rate for Payer: Humana KY Medicaid |
$27.44
|
| Rate for Payer: Kentucky WC Medicaid |
$27.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.22
|
| Rate for Payer: Ohio Health Group HMO |
$59.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.06
|
| Rate for Payer: PHCS Commercial |
$76.60
|
| Rate for Payer: United Healthcare All Payer |
$70.22
|
|
|
DEXTROSE 5% SINGLES 1 5%/100ML
|
Facility
|
IP
|
$79.79
|
|
|
Service Code
|
NDC 990792323
|
| Hospital Charge Code |
25003007
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$76.60 |
| Rate for Payer: Aetna Commercial |
$61.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.24
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$66.23
|
| Rate for Payer: First Health Commercial |
$75.80
|
| Rate for Payer: Humana Commercial |
$67.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.22
|
| Rate for Payer: Ohio Health Group HMO |
$59.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.06
|
| Rate for Payer: PHCS Commercial |
$76.60
|
| Rate for Payer: United Healthcare All Payer |
$70.22
|
|
|
DEXTROSE 5%(VISIV)250ML IVSOLN
|
Facility
|
OP
|
$69.14
|
|
|
Service Code
|
NDC 338006230
|
| Hospital Charge Code |
25003008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$20.74 |
| Max. Negotiated Rate |
$66.37 |
| Rate for Payer: Aetna Commercial |
$53.24
|
| Rate for Payer: Anthem Medicaid |
$23.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.93
|
| Rate for Payer: Cash Price |
$34.57
|
| Rate for Payer: Cigna Commercial |
$57.39
|
| Rate for Payer: First Health Commercial |
$65.68
|
| Rate for Payer: Humana Commercial |
$58.77
|
| Rate for Payer: Humana KY Medicaid |
$23.78
|
| Rate for Payer: Kentucky WC Medicaid |
$24.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.71
|
| Rate for Payer: PHCS Commercial |
$66.37
|
| Rate for Payer: United Healthcare All Payer |
$60.84
|
|
|
DEXTROSE 5%(VISIV)250ML IVSOLN
|
Facility
|
IP
|
$69.14
|
|
|
Service Code
|
NDC 338006230
|
| Hospital Charge Code |
25003008
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$20.74 |
| Max. Negotiated Rate |
$66.37 |
| Rate for Payer: Aetna Commercial |
$53.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.93
|
| Rate for Payer: Cash Price |
$34.57
|
| Rate for Payer: Cigna Commercial |
$57.39
|
| Rate for Payer: First Health Commercial |
$65.68
|
| Rate for Payer: Humana Commercial |
$58.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.71
|
| Rate for Payer: PHCS Commercial |
$66.37
|
| Rate for Payer: United Healthcare All Payer |
$60.84
|
|
|
DEXTROSE 70% 500ML
|
Facility
|
IP
|
$122.75
|
|
|
Service Code
|
NDC 990791819
|
| Hospital Charge Code |
25003017
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.83 |
| Max. Negotiated Rate |
$117.84 |
| Rate for Payer: Aetna Commercial |
$94.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.75
|
| Rate for Payer: Cash Price |
$61.38
|
| Rate for Payer: Cigna Commercial |
$101.88
|
| Rate for Payer: First Health Commercial |
$116.61
|
| Rate for Payer: Humana Commercial |
$104.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.02
|
| Rate for Payer: Ohio Health Group HMO |
$92.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.70
|
| Rate for Payer: PHCS Commercial |
$117.84
|
| Rate for Payer: United Healthcare All Payer |
$108.02
|
|
|
DEXTROSE 70% 500ML
|
Facility
|
OP
|
$122.75
|
|
|
Service Code
|
NDC 990791819
|
| Hospital Charge Code |
25003017
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.83 |
| Max. Negotiated Rate |
$117.84 |
| Rate for Payer: Aetna Commercial |
$94.52
|
| Rate for Payer: Anthem Medicaid |
$42.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.75
|
| Rate for Payer: Cash Price |
$61.38
|
| Rate for Payer: Cigna Commercial |
$101.88
|
| Rate for Payer: First Health Commercial |
$116.61
|
| Rate for Payer: Humana Commercial |
$104.34
|
| Rate for Payer: Humana KY Medicaid |
$42.21
|
| Rate for Payer: Kentucky WC Medicaid |
$42.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.02
|
| Rate for Payer: Ohio Health Group HMO |
$92.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.70
|
| Rate for Payer: PHCS Commercial |
$117.84
|
| Rate for Payer: United Healthcare All Payer |
$108.02
|
|
|
DEXTROSE D5/W 0.9% NACL 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003018
|
|
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 D5/W 0.9% NACL 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
25003018
|
|
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
|
|
|
DGW SV .018 180CM SHORT ST
|
Facility
|
IP
|
$1,170.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$1,123.20 |
| Rate for Payer: Aetna Commercial |
$900.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.60
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$971.10
|
| Rate for Payer: First Health Commercial |
$1,111.50
|
| Rate for Payer: Humana Commercial |
$994.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.60
|
| Rate for Payer: Ohio Health Group HMO |
$877.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,017.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.30
|
| Rate for Payer: PHCS Commercial |
$1,123.20
|
| Rate for Payer: United Healthcare All Payer |
$1,029.60
|
|
|
DGW SV .018 180CM SHORT ST
|
Facility
|
OP
|
$1,170.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$1,123.20 |
| Rate for Payer: Aetna Commercial |
$900.90
|
| Rate for Payer: Anthem Medicaid |
$402.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.60
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$971.10
|
| Rate for Payer: First Health Commercial |
$1,111.50
|
| Rate for Payer: Humana Commercial |
$994.50
|
| Rate for Payer: Humana KY Medicaid |
$402.36
|
| Rate for Payer: Kentucky WC Medicaid |
$406.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$410.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.60
|
| Rate for Payer: Ohio Health Group HMO |
$877.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,017.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.30
|
| Rate for Payer: PHCS Commercial |
$1,123.20
|
| Rate for Payer: United Healthcare All Payer |
$1,029.60
|
|
|
DGW SV .018 300CM SHORT ST
|
Facility
|
OP
|
$1,170.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$1,123.20 |
| Rate for Payer: Aetna Commercial |
$900.90
|
| Rate for Payer: Anthem Medicaid |
$402.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.60
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$971.10
|
| Rate for Payer: First Health Commercial |
$1,111.50
|
| Rate for Payer: Humana Commercial |
$994.50
|
| Rate for Payer: Humana KY Medicaid |
$402.36
|
| Rate for Payer: Kentucky WC Medicaid |
$406.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$410.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.60
|
| Rate for Payer: Ohio Health Group HMO |
$877.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,017.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.30
|
| Rate for Payer: PHCS Commercial |
$1,123.20
|
| Rate for Payer: United Healthcare All Payer |
$1,029.60
|
|
|
DGW SV .018 300CM SHORT ST
|
Facility
|
IP
|
$1,170.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$1,123.20 |
| Rate for Payer: Aetna Commercial |
$900.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.60
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$971.10
|
| Rate for Payer: First Health Commercial |
$1,111.50
|
| Rate for Payer: Humana Commercial |
$994.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.60
|
| Rate for Payer: Ohio Health Group HMO |
$877.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,017.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.30
|
| Rate for Payer: PHCS Commercial |
$1,123.20
|
| Rate for Payer: United Healthcare All Payer |
$1,029.60
|
|
|
DHE 45(DIHYROERGOTAMIN 1MG/1ML
|
Facility
|
OP
|
$577.50
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
25002018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.25 |
| Max. Negotiated Rate |
$554.40 |
| Rate for Payer: Aetna Commercial |
$444.68
|
| Rate for Payer: Anthem Medicaid |
$198.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.45
|
| Rate for Payer: Cash Price |
$288.75
|
| Rate for Payer: Cigna Commercial |
$479.32
|
| Rate for Payer: First Health Commercial |
$548.62
|
| Rate for Payer: Humana Commercial |
$490.88
|
| Rate for Payer: Humana KY Medicaid |
$198.60
|
| Rate for Payer: Kentucky WC Medicaid |
$200.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$426.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$202.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$508.20
|
| Rate for Payer: Ohio Health Group HMO |
$433.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.48
|
| Rate for Payer: PHCS Commercial |
$554.40
|
| Rate for Payer: United Healthcare All Payer |
$508.20
|
|
|
DHE 45(DIHYROERGOTAMIN 1MG/1ML
|
Facility
|
IP
|
$577.50
|
|
|
Service Code
|
HCPCS J1110
|
| Hospital Charge Code |
25002018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.25 |
| Max. Negotiated Rate |
$554.40 |
| Rate for Payer: Aetna Commercial |
$444.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.45
|
| Rate for Payer: Cash Price |
$288.75
|
| Rate for Payer: Cigna Commercial |
$479.32
|
| Rate for Payer: First Health Commercial |
$548.62
|
| Rate for Payer: Humana Commercial |
$490.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$426.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$508.20
|
| Rate for Payer: Ohio Health Group HMO |
$433.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.48
|
| Rate for Payer: PHCS Commercial |
$554.40
|
| Rate for Payer: United Healthcare All Payer |
$508.20
|
|
|
DHE NASAL 4mg
|
Facility
|
IP
|
$72.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004514
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$69.60 |
| Rate for Payer: Aetna Commercial |
$55.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.55
|
| Rate for Payer: Cash Price |
$36.25
|
| Rate for Payer: Cigna Commercial |
$60.17
|
| Rate for Payer: First Health Commercial |
$68.88
|
| Rate for Payer: Humana Commercial |
$61.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.80
|
| Rate for Payer: Ohio Health Group HMO |
$54.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.02
|
| Rate for Payer: PHCS Commercial |
$69.60
|
| Rate for Payer: United Healthcare All Payer |
$63.80
|
|
|
DHE NASAL 4mg
|
Facility
|
OP
|
$72.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004514
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$69.60 |
| Rate for Payer: Aetna Commercial |
$55.83
|
| Rate for Payer: Anthem Medicaid |
$24.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.55
|
| Rate for Payer: Cash Price |
$36.25
|
| Rate for Payer: Cigna Commercial |
$60.17
|
| Rate for Payer: First Health Commercial |
$68.88
|
| Rate for Payer: Humana Commercial |
$61.62
|
| Rate for Payer: Humana KY Medicaid |
$24.93
|
| Rate for Payer: Kentucky WC Medicaid |
$25.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.80
|
| Rate for Payer: Ohio Health Group HMO |
$54.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.02
|
| Rate for Payer: PHCS Commercial |
$69.60
|
| Rate for Payer: United Healthcare All Payer |
$63.80
|
|
|
DIABETA (GLYBURIDE) 2.5MG/1TAB
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 93834301
|
| Hospital Charge Code |
25000549
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.01
|
| Rate for Payer: PHCS Commercial |
$4.19
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
|
|
DIABETA (GLYBURIDE) 2.5MG/1TAB
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 93834301
|
| Hospital Charge Code |
25000549
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.01
|
| Rate for Payer: PHCS Commercial |
$4.19
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
|
|
DIABETA (GLYBURIDE) 5 5MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 72241004005
|
| Hospital Charge Code |
25000550
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
DIABETA (GLYBURIDE) 5 5MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 72241004005
|
| Hospital Charge Code |
25000550
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
DIABETES EDUC GROUP 30MIN
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
94200012
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
DIABETES EDUC GROUP 30MIN
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
94200012
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
DIABETES EDUC IND 30MIN
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
94200011
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
DIABETES EDUC IND 30MIN
|
Professional
|
Both
|
$116.00
|
|
| Hospital Charge Code |
94200011
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$81.20 |
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Multiplan PHCS |
$69.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$81.20
|
| Rate for Payer: UHCCP Medicaid |
$40.60
|
|
|
DIABETES EDUC IND 30MIN
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
94200011
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
