|
DLY TREATMNT 2 AREAS 6-10 MEV
|
Facility
|
OP
|
$336.00
|
|
|
Service Code
|
HCPCS 77407
|
| Hospital Charge Code |
33300025
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$115.55 |
| Max. Negotiated Rate |
$340.19 |
| Rate for Payer: Aetna Commercial |
$258.72
|
| Rate for Payer: Anthem Medicaid |
$115.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$242.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$340.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$328.04
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$278.88
|
| Rate for Payer: First Health Commercial |
$319.20
|
| Rate for Payer: Humana Commercial |
$285.60
|
| Rate for Payer: Humana KY Medicaid |
$115.55
|
| Rate for Payer: Humana Medicare Advantage |
$242.99
|
| Rate for Payer: Kentucky WC Medicaid |
$116.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$275.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$295.68
|
| Rate for Payer: Ohio Health Group HMO |
$252.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$292.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.84
|
| Rate for Payer: PHCS Commercial |
$322.56
|
| Rate for Payer: United Healthcare All Payer |
$295.68
|
|
|
DLY TRTMNT 3 AREAS 11-19 MEV
|
Facility
|
OP
|
$804.00
|
|
|
Service Code
|
HCPCS 77412
|
| Hospital Charge Code |
33300026
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$242.99 |
| Max. Negotiated Rate |
$771.84 |
| Rate for Payer: Aetna Commercial |
$619.08
|
| Rate for Payer: Anthem Medicaid |
$276.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$242.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$627.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$340.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$328.04
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cigna Commercial |
$667.32
|
| Rate for Payer: First Health Commercial |
$763.80
|
| Rate for Payer: Humana Commercial |
$683.40
|
| Rate for Payer: Humana KY Medicaid |
$276.50
|
| Rate for Payer: Humana Medicare Advantage |
$242.99
|
| Rate for Payer: Kentucky WC Medicaid |
$279.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$659.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$593.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$282.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$707.52
|
| Rate for Payer: Ohio Health Group HMO |
$603.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$643.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$699.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$554.76
|
| Rate for Payer: PHCS Commercial |
$771.84
|
| Rate for Payer: United Healthcare All Payer |
$707.52
|
|
|
DLY TRTMNT 3 AREAS 11-19 MEV
|
Facility
|
IP
|
$804.00
|
|
|
Service Code
|
HCPCS 77412
|
| Hospital Charge Code |
33300026
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$241.20 |
| Max. Negotiated Rate |
$771.84 |
| Rate for Payer: Aetna Commercial |
$619.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$627.12
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cigna Commercial |
$667.32
|
| Rate for Payer: First Health Commercial |
$763.80
|
| Rate for Payer: Humana Commercial |
$683.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$659.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$593.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$241.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$707.52
|
| Rate for Payer: Ohio Health Group HMO |
$603.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$643.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$699.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$554.76
|
| Rate for Payer: PHCS Commercial |
$771.84
|
| Rate for Payer: United Healthcare All Payer |
$707.52
|
|
|
DM RN EDUC 30MIN CORESOURCE/SP
|
Facility
|
IP
|
$103.50
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
76102511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.05 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$79.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.73
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cigna Commercial |
$85.91
|
| Rate for Payer: First Health Commercial |
$98.33
|
| Rate for Payer: Humana Commercial |
$87.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.08
|
| Rate for Payer: Ohio Health Group HMO |
$77.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.42
|
| Rate for Payer: PHCS Commercial |
$99.36
|
| Rate for Payer: United Healthcare All Payer |
$91.08
|
|
|
DM RN EDUC 30MIN CORESOURCE/SP
|
Professional
|
Both
|
$103.50
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
76102511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$22.53 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna Commercial |
$35.51
|
| Rate for Payer: Anthem Medicaid |
$22.53
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cigna Commercial |
$23.51
|
| Rate for Payer: Humana Medicaid |
$22.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$32.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.98
|
| Rate for Payer: Molina Healthcare Passport |
$22.53
|
| Rate for Payer: Multiplan PHCS |
$62.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.45
|
| Rate for Payer: UHCCP Medicaid |
$36.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.76
|
|
|
DM RN EDUC 30MIN CORESOURCE/SP
|
Facility
|
OP
|
$103.50
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
76102511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.05 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$79.69
|
| Rate for Payer: Anthem Medicaid |
$35.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.73
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Cigna Commercial |
$85.91
|
| Rate for Payer: First Health Commercial |
$98.33
|
| Rate for Payer: Humana Commercial |
$87.97
|
| Rate for Payer: Humana KY Medicaid |
$35.59
|
| Rate for Payer: Kentucky WC Medicaid |
$35.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.08
|
| Rate for Payer: Ohio Health Group HMO |
$77.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.42
|
| Rate for Payer: PHCS Commercial |
$99.36
|
| Rate for Payer: United Healthcare All Payer |
$91.08
|
|
|
DOBUTAMINE-DXTRSE 1000MG/250ML
|
Facility
|
OP
|
$185.23
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.57 |
| Max. Negotiated Rate |
$177.82 |
| Rate for Payer: Aetna Commercial |
$142.63
|
| Rate for Payer: Anthem Medicaid |
$63.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.48
|
| Rate for Payer: Cash Price |
$92.61
|
| Rate for Payer: Cigna Commercial |
$153.74
|
| Rate for Payer: First Health Commercial |
$175.97
|
| Rate for Payer: Humana Commercial |
$157.45
|
| Rate for Payer: Humana KY Medicaid |
$63.70
|
| Rate for Payer: Kentucky WC Medicaid |
$64.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.00
|
| Rate for Payer: Ohio Health Group HMO |
$138.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.81
|
| Rate for Payer: PHCS Commercial |
$177.82
|
| Rate for Payer: United Healthcare All Payer |
$163.00
|
|
|
DOBUTAMINE-DXTRSE 1000MG/250ML
|
Facility
|
IP
|
$185.23
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.57 |
| Max. Negotiated Rate |
$177.82 |
| Rate for Payer: Aetna Commercial |
$142.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.48
|
| Rate for Payer: Cash Price |
$92.61
|
| Rate for Payer: Cigna Commercial |
$153.74
|
| Rate for Payer: First Health Commercial |
$175.97
|
| Rate for Payer: Humana Commercial |
$157.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.00
|
| Rate for Payer: Ohio Health Group HMO |
$138.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.81
|
| Rate for Payer: PHCS Commercial |
$177.82
|
| Rate for Payer: United Healthcare All Payer |
$163.00
|
|
|
DOBUTREX (DOBUTAMIN 250MG/20ML
|
Facility
|
IP
|
$113.93
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$109.37 |
| Rate for Payer: Aetna Commercial |
$87.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.87
|
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: First Health Commercial |
$108.23
|
| Rate for Payer: Humana Commercial |
$96.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.26
|
| Rate for Payer: Ohio Health Group HMO |
$85.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
DOBUTREX (DOBUTAMIN 250MG/20ML
|
Facility
|
OP
|
$113.93
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
25002039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$109.37 |
| Rate for Payer: Aetna Commercial |
$87.73
|
| Rate for Payer: Anthem Medicaid |
$39.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.87
|
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: First Health Commercial |
$108.23
|
| Rate for Payer: Humana Commercial |
$96.84
|
| Rate for Payer: Humana KY Medicaid |
$39.18
|
| Rate for Payer: Kentucky WC Medicaid |
$39.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.26
|
| Rate for Payer: Ohio Health Group HMO |
$85.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
DOCETAXEL 1mg (20mg/2mL SDV)
|
Facility
|
OP
|
$380.30
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.09 |
| Max. Negotiated Rate |
$365.09 |
| Rate for Payer: Aetna Commercial |
$292.83
|
| Rate for Payer: Anthem Medicaid |
$130.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.63
|
| Rate for Payer: Cash Price |
$190.15
|
| Rate for Payer: Cigna Commercial |
$315.65
|
| Rate for Payer: First Health Commercial |
$361.29
|
| Rate for Payer: Humana Commercial |
$323.25
|
| Rate for Payer: Humana KY Medicaid |
$130.79
|
| Rate for Payer: Kentucky WC Medicaid |
$132.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$133.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.66
|
| Rate for Payer: Ohio Health Group HMO |
$285.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$330.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.41
|
| Rate for Payer: PHCS Commercial |
$365.09
|
| Rate for Payer: United Healthcare All Payer |
$334.66
|
|
|
DOCETAXEL 1mg (20mg/2mL SDV)
|
Facility
|
IP
|
$380.30
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.09 |
| Max. Negotiated Rate |
$365.09 |
| Rate for Payer: Aetna Commercial |
$292.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.63
|
| Rate for Payer: Cash Price |
$190.15
|
| Rate for Payer: Cigna Commercial |
$315.65
|
| Rate for Payer: First Health Commercial |
$361.29
|
| Rate for Payer: Humana Commercial |
$323.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.66
|
| Rate for Payer: Ohio Health Group HMO |
$285.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$330.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.41
|
| Rate for Payer: PHCS Commercial |
$365.09
|
| Rate for Payer: United Healthcare All Payer |
$334.66
|
|
|
DOCETAXEL 1mg (from 160mg MDV)
|
Facility
|
IP
|
$5.78
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.51
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna Commercial |
$4.80
|
| Rate for Payer: First Health Commercial |
$5.49
|
| Rate for Payer: Humana Commercial |
$4.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.09
|
| Rate for Payer: Ohio Health Group HMO |
$4.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.99
|
| Rate for Payer: PHCS Commercial |
$5.55
|
| Rate for Payer: United Healthcare All Payer |
$5.09
|
|
|
DOCETAXEL 1mg (from 160mg MDV)
|
Facility
|
OP
|
$5.78
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25004475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Anthem Medicaid |
$1.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.51
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna Commercial |
$4.80
|
| Rate for Payer: First Health Commercial |
$5.49
|
| Rate for Payer: Humana Commercial |
$4.91
|
| Rate for Payer: Humana KY Medicaid |
$1.99
|
| Rate for Payer: Kentucky WC Medicaid |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.09
|
| Rate for Payer: Ohio Health Group HMO |
$4.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.99
|
| Rate for Payer: PHCS Commercial |
$5.55
|
| Rate for Payer: United Healthcare All Payer |
$5.09
|
|
|
DOC EXT. WIRE
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
DOC EXT. WIRE
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
DOC WIRE RUNTHROUGH
|
Facility
|
OP
|
$1,504.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$451.20 |
| Max. Negotiated Rate |
$1,443.84 |
| Rate for Payer: Aetna Commercial |
$1,158.08
|
| Rate for Payer: Anthem Medicaid |
$517.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,173.12
|
| Rate for Payer: Cash Price |
$752.00
|
| Rate for Payer: Cigna Commercial |
$1,248.32
|
| Rate for Payer: First Health Commercial |
$1,428.80
|
| Rate for Payer: Humana Commercial |
$1,278.40
|
| Rate for Payer: Humana KY Medicaid |
$517.23
|
| Rate for Payer: Kentucky WC Medicaid |
$522.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,233.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,109.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$527.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,323.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,308.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,037.76
|
| Rate for Payer: PHCS Commercial |
$1,443.84
|
| Rate for Payer: United Healthcare All Payer |
$1,323.52
|
|
|
DOC WIRE RUNTHROUGH
|
Facility
|
IP
|
$1,504.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$451.20 |
| Max. Negotiated Rate |
$1,443.84 |
| Rate for Payer: Aetna Commercial |
$1,158.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,173.12
|
| Rate for Payer: Cash Price |
$752.00
|
| Rate for Payer: Cigna Commercial |
$1,248.32
|
| Rate for Payer: First Health Commercial |
$1,428.80
|
| Rate for Payer: Humana Commercial |
$1,278.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,233.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,109.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,323.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,308.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,037.76
|
| Rate for Payer: PHCS Commercial |
$1,443.84
|
| Rate for Payer: United Healthcare All Payer |
$1,323.52
|
|
|
DOGDANDER IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000730
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DOGDANDER IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000730
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DOLOBID (DIFLUNISAL 500MG/1TAB
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
NDC 93922201
|
| Hospital Charge Code |
25000578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.66
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
DOLOBID (DIFLUNISAL 500MG/1TAB
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
NDC 93922201
|
| Hospital Charge Code |
25000578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem Medicaid |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Humana KY Medicaid |
$3.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.66
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
DOMEBORO POWDER PACK 2.2GM/1EA
|
Facility
|
IP
|
$4.87
|
|
|
Service Code
|
NDC 16864024001
|
| Hospital Charge Code |
25000579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DOMEBORO POWDER PACK 2.2GM/1EA
|
Facility
|
OP
|
$4.87
|
|
|
Service Code
|
NDC 16864024001
|
| Hospital Charge Code |
25000579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DONNATAL (BELLAD/PB) ELIXI 5ML
|
Facility
|
IP
|
$11.07
|
|
|
Service Code
|
NDC 50742066516
|
| Hospital Charge Code |
25003026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Aetna Commercial |
$8.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.63
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.19
|
| Rate for Payer: First Health Commercial |
$10.52
|
| Rate for Payer: Humana Commercial |
$9.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.74
|
| Rate for Payer: Ohio Health Group HMO |
$8.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.64
|
| Rate for Payer: PHCS Commercial |
$10.63
|
| Rate for Payer: United Healthcare All Payer |
$9.74
|
|
