|
DOSIMETRY BASIC(T
|
Facility
|
IP
|
$424.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
333T0006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$127.20 |
| Max. Negotiated Rate |
$407.04 |
| Rate for Payer: Aetna Commercial |
$326.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$330.72
|
| Rate for Payer: Cash Price |
$212.00
|
| Rate for Payer: Cigna Commercial |
$351.92
|
| Rate for Payer: First Health Commercial |
$402.80
|
| Rate for Payer: Humana Commercial |
$360.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$347.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$312.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$373.12
|
| Rate for Payer: Ohio Health Group HMO |
$318.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$339.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$368.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$292.56
|
| Rate for Payer: PHCS Commercial |
$407.04
|
| Rate for Payer: United Healthcare All Payer |
$373.12
|
|
|
DOSIMETRY BASIC(T
|
Facility
|
OP
|
$424.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
333T0006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$407.04 |
| Rate for Payer: Aetna Commercial |
$326.48
|
| Rate for Payer: Anthem Medicaid |
$145.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$122.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$330.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$171.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.62
|
| Rate for Payer: Cash Price |
$212.00
|
| Rate for Payer: Cash Price |
$212.00
|
| Rate for Payer: Cigna Commercial |
$351.92
|
| Rate for Payer: First Health Commercial |
$402.80
|
| Rate for Payer: Humana Commercial |
$360.40
|
| Rate for Payer: Humana KY Medicaid |
$145.81
|
| Rate for Payer: Humana Medicare Advantage |
$122.68
|
| Rate for Payer: Kentucky WC Medicaid |
$147.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$347.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$312.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$148.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$373.12
|
| Rate for Payer: Ohio Health Group HMO |
$318.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$339.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$368.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$292.56
|
| Rate for Payer: PHCS Commercial |
$407.04
|
| Rate for Payer: United Healthcare All Payer |
$373.12
|
|
|
DOSTINEX 0.5MG TABLET
|
Facility
|
IP
|
$22.85
|
|
|
Service Code
|
HCPCS J8515
|
| Hospital Charge Code |
25002532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.82
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cigna Commercial |
$18.97
|
| Rate for Payer: First Health Commercial |
$21.71
|
| Rate for Payer: Humana Commercial |
$19.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.11
|
| Rate for Payer: Ohio Health Group HMO |
$17.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.77
|
| Rate for Payer: PHCS Commercial |
$21.94
|
| Rate for Payer: United Healthcare All Payer |
$20.11
|
|
|
DOSTINEX 0.5MG TABLET
|
Facility
|
OP
|
$22.85
|
|
|
Service Code
|
HCPCS J8515
|
| Hospital Charge Code |
25002532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Anthem Medicaid |
$7.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.82
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cigna Commercial |
$18.97
|
| Rate for Payer: First Health Commercial |
$21.71
|
| Rate for Payer: Humana Commercial |
$19.42
|
| Rate for Payer: Humana KY Medicaid |
$7.86
|
| Rate for Payer: Kentucky WC Medicaid |
$7.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.11
|
| Rate for Payer: Ohio Health Group HMO |
$17.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.77
|
| Rate for Payer: PHCS Commercial |
$21.94
|
| Rate for Payer: United Healthcare All Payer |
$20.11
|
|
|
DOTAREM 0.5MMOL/ML 100ML VIAL
|
Facility
|
IP
|
$643.33
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$193.00 |
| Max. Negotiated Rate |
$617.60 |
| Rate for Payer: Aetna Commercial |
$495.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$501.80
|
| Rate for Payer: Cash Price |
$321.66
|
| Rate for Payer: Cigna Commercial |
$533.96
|
| Rate for Payer: First Health Commercial |
$611.16
|
| Rate for Payer: Humana Commercial |
$546.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$527.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$474.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$193.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$566.13
|
| Rate for Payer: Ohio Health Group HMO |
$482.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$514.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$443.90
|
| Rate for Payer: PHCS Commercial |
$617.60
|
| Rate for Payer: United Healthcare All Payer |
$566.13
|
|
|
DOTAREM 0.5MMOL/ML 100ML VIAL
|
Facility
|
OP
|
$643.33
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$193.00 |
| Max. Negotiated Rate |
$617.60 |
| Rate for Payer: Aetna Commercial |
$495.36
|
| Rate for Payer: Anthem Medicaid |
$221.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$501.80
|
| Rate for Payer: Cash Price |
$321.66
|
| Rate for Payer: Cigna Commercial |
$533.96
|
| Rate for Payer: First Health Commercial |
$611.16
|
| Rate for Payer: Humana Commercial |
$546.83
|
| Rate for Payer: Humana KY Medicaid |
$221.24
|
| Rate for Payer: Kentucky WC Medicaid |
$223.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$527.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$474.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$193.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$225.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$566.13
|
| Rate for Payer: Ohio Health Group HMO |
$482.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$514.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$443.90
|
| Rate for Payer: PHCS Commercial |
$617.60
|
| Rate for Payer: United Healthcare All Payer |
$566.13
|
|
|
DOTAREM 0.5MMOL/ML 10ML VIAL
|
Facility
|
OP
|
$71.50
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.45 |
| Max. Negotiated Rate |
$68.64 |
| Rate for Payer: Aetna Commercial |
$55.05
|
| Rate for Payer: Anthem Medicaid |
$24.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.77
|
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Cigna Commercial |
$59.34
|
| Rate for Payer: First Health Commercial |
$67.92
|
| Rate for Payer: Humana Commercial |
$60.77
|
| Rate for Payer: Humana KY Medicaid |
$24.59
|
| Rate for Payer: Kentucky WC Medicaid |
$24.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.92
|
| Rate for Payer: Ohio Health Group HMO |
$53.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.34
|
| Rate for Payer: PHCS Commercial |
$68.64
|
| Rate for Payer: United Healthcare All Payer |
$62.92
|
|
|
DOTAREM 0.5MMOL/ML 10ML VIAL
|
Facility
|
IP
|
$71.50
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.45 |
| Max. Negotiated Rate |
$68.64 |
| Rate for Payer: Aetna Commercial |
$55.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.77
|
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Cigna Commercial |
$59.34
|
| Rate for Payer: First Health Commercial |
$67.92
|
| Rate for Payer: Humana Commercial |
$60.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.92
|
| Rate for Payer: Ohio Health Group HMO |
$53.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.34
|
| Rate for Payer: PHCS Commercial |
$68.64
|
| Rate for Payer: United Healthcare All Payer |
$62.92
|
|
|
DOTAREM 0.5MMOL/ML 15ML VIAL
|
Facility
|
IP
|
$133.20
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.96 |
| Max. Negotiated Rate |
$127.87 |
| Rate for Payer: Aetna Commercial |
$102.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.90
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$110.56
|
| Rate for Payer: First Health Commercial |
$126.54
|
| Rate for Payer: Humana Commercial |
$113.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.22
|
| Rate for Payer: Ohio Health Group HMO |
$99.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$115.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.91
|
| Rate for Payer: PHCS Commercial |
$127.87
|
| Rate for Payer: United Healthcare All Payer |
$117.22
|
|
|
DOTAREM 0.5MMOL/ML 15ML VIAL
|
Facility
|
OP
|
$133.20
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.96 |
| Max. Negotiated Rate |
$127.87 |
| Rate for Payer: Aetna Commercial |
$102.56
|
| Rate for Payer: Anthem Medicaid |
$45.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.90
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$110.56
|
| Rate for Payer: First Health Commercial |
$126.54
|
| Rate for Payer: Humana Commercial |
$113.22
|
| Rate for Payer: Humana KY Medicaid |
$45.81
|
| Rate for Payer: Kentucky WC Medicaid |
$46.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.22
|
| Rate for Payer: Ohio Health Group HMO |
$99.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$115.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.91
|
| Rate for Payer: PHCS Commercial |
$127.87
|
| Rate for Payer: United Healthcare All Payer |
$117.22
|
|
|
DOTAREM 0.5MMOL/ML 20ML VIAL
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$127.68 |
| Rate for Payer: Aetna Commercial |
$102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.74
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cigna Commercial |
$110.39
|
| Rate for Payer: First Health Commercial |
$126.35
|
| Rate for Payer: Humana Commercial |
$113.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.04
|
| Rate for Payer: Ohio Health Group HMO |
$99.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$115.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.77
|
| Rate for Payer: PHCS Commercial |
$127.68
|
| Rate for Payer: United Healthcare All Payer |
$117.04
|
|
|
DOTAREM 0.5MMOL/ML 20ML VIAL
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$127.68 |
| Rate for Payer: Aetna Commercial |
$102.41
|
| Rate for Payer: Anthem Medicaid |
$45.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.74
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cigna Commercial |
$110.39
|
| Rate for Payer: First Health Commercial |
$126.35
|
| Rate for Payer: Humana Commercial |
$113.05
|
| Rate for Payer: Humana KY Medicaid |
$45.74
|
| Rate for Payer: Kentucky WC Medicaid |
$46.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.04
|
| Rate for Payer: Ohio Health Group HMO |
$99.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$115.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.77
|
| Rate for Payer: PHCS Commercial |
$127.68
|
| Rate for Payer: United Healthcare All Payer |
$117.04
|
|
|
DOTAREM 0.5MOL/ML 5ML VIAL
|
Facility
|
IP
|
$45.75
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$43.92 |
| Rate for Payer: Aetna Commercial |
$35.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.69
|
| Rate for Payer: Cash Price |
$22.88
|
| Rate for Payer: Cigna Commercial |
$37.97
|
| Rate for Payer: First Health Commercial |
$43.46
|
| Rate for Payer: Humana Commercial |
$38.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$37.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$40.26
|
| Rate for Payer: Ohio Health Group HMO |
$34.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.57
|
| Rate for Payer: PHCS Commercial |
$43.92
|
| Rate for Payer: United Healthcare All Payer |
$40.26
|
|
|
DOTAREM 0.5MOL/ML 5ML VIAL
|
Facility
|
OP
|
$45.75
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$43.92 |
| Rate for Payer: Aetna Commercial |
$35.23
|
| Rate for Payer: Anthem Medicaid |
$15.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.69
|
| Rate for Payer: Cash Price |
$22.88
|
| Rate for Payer: Cigna Commercial |
$37.97
|
| Rate for Payer: First Health Commercial |
$43.46
|
| Rate for Payer: Humana Commercial |
$38.89
|
| Rate for Payer: Humana KY Medicaid |
$15.73
|
| Rate for Payer: Kentucky WC Medicaid |
$15.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$37.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$40.26
|
| Rate for Payer: Ohio Health Group HMO |
$34.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.57
|
| Rate for Payer: PHCS Commercial |
$43.92
|
| Rate for Payer: United Healthcare All Payer |
$40.26
|
|
|
DOVONEX 0.005% CREAM(60GM)
|
Facility
|
OP
|
$10.64
|
|
|
Service Code
|
NDC 68462050165
|
| Hospital Charge Code |
25003031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$10.21 |
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: Anthem Medicaid |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.30
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Cigna Commercial |
$8.83
|
| Rate for Payer: First Health Commercial |
$10.11
|
| Rate for Payer: Humana Commercial |
$9.04
|
| Rate for Payer: Humana KY Medicaid |
$3.66
|
| Rate for Payer: Kentucky WC Medicaid |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.34
|
| Rate for Payer: PHCS Commercial |
$10.21
|
| Rate for Payer: United Healthcare All Payer |
$9.36
|
|
|
DOVONEX 0.005% CREAM(60GM)
|
Facility
|
IP
|
$10.64
|
|
|
Service Code
|
NDC 68462050165
|
| Hospital Charge Code |
25003031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$10.21 |
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.30
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Cigna Commercial |
$8.83
|
| Rate for Payer: First Health Commercial |
$10.11
|
| Rate for Payer: Humana Commercial |
$9.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.34
|
| Rate for Payer: PHCS Commercial |
$10.21
|
| Rate for Payer: United Healthcare All Payer |
$9.36
|
|
|
DOXEPIN 10NG/ML ORAL CON (1ML)
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 54838051240
|
| Hospital Charge Code |
25000580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
DOXEPIN 10NG/ML ORAL CON (1ML)
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
NDC 54838051240
|
| Hospital Charge Code |
25000580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
DOXIL 10MG 20MG/10ML VL
|
Facility
|
IP
|
$1,744.87
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25002718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$523.46 |
| Max. Negotiated Rate |
$1,675.08 |
| Rate for Payer: Aetna Commercial |
$1,343.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,361.00
|
| Rate for Payer: Cash Price |
$872.43
|
| Rate for Payer: Cigna Commercial |
$1,448.24
|
| Rate for Payer: First Health Commercial |
$1,657.63
|
| Rate for Payer: Humana Commercial |
$1,483.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,430.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,287.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$523.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,535.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,308.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,395.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,203.96
|
| Rate for Payer: PHCS Commercial |
$1,675.08
|
| Rate for Payer: United Healthcare All Payer |
$1,535.49
|
|
|
DOXIL 10MG 20MG/10ML VL
|
Facility
|
OP
|
$1,744.87
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25002718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.28 |
| Max. Negotiated Rate |
$1,675.08 |
| Rate for Payer: Aetna Commercial |
$1,343.55
|
| Rate for Payer: Anthem Medicaid |
$600.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$109.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,361.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$152.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.53
|
| Rate for Payer: Cash Price |
$872.43
|
| Rate for Payer: Cash Price |
$872.43
|
| Rate for Payer: Cigna Commercial |
$1,448.24
|
| Rate for Payer: First Health Commercial |
$1,657.63
|
| Rate for Payer: Humana Commercial |
$1,483.14
|
| Rate for Payer: Humana KY Medicaid |
$600.06
|
| Rate for Payer: Humana Medicare Advantage |
$109.28
|
| Rate for Payer: Kentucky WC Medicaid |
$606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,430.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,287.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$131.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$612.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,535.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,308.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,395.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,203.96
|
| Rate for Payer: PHCS Commercial |
$1,675.08
|
| Rate for Payer: United Healthcare All Payer |
$1,535.49
|
|
|
DOXIL 10MG 50MG/25ML VL
|
Facility
|
IP
|
$9,177.80
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25003777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,753.34 |
| Max. Negotiated Rate |
$8,810.69 |
| Rate for Payer: Aetna Commercial |
$7,066.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,158.68
|
| Rate for Payer: Cash Price |
$4,588.90
|
| Rate for Payer: Cigna Commercial |
$7,617.57
|
| Rate for Payer: First Health Commercial |
$8,718.91
|
| Rate for Payer: Humana Commercial |
$7,801.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,525.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,773.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,753.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,076.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,883.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,342.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,984.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,332.68
|
| Rate for Payer: PHCS Commercial |
$8,810.69
|
| Rate for Payer: United Healthcare All Payer |
$8,076.46
|
|
|
DOXIL 10MG 50MG/25ML VL
|
Facility
|
OP
|
$9,177.80
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25003777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.28 |
| Max. Negotiated Rate |
$8,810.69 |
| Rate for Payer: Aetna Commercial |
$7,066.91
|
| Rate for Payer: Anthem Medicaid |
$3,156.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$109.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,158.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$152.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.53
|
| Rate for Payer: Cash Price |
$4,588.90
|
| Rate for Payer: Cash Price |
$4,588.90
|
| Rate for Payer: Cigna Commercial |
$7,617.57
|
| Rate for Payer: First Health Commercial |
$8,718.91
|
| Rate for Payer: Humana Commercial |
$7,801.13
|
| Rate for Payer: Humana KY Medicaid |
$3,156.25
|
| Rate for Payer: Humana Medicare Advantage |
$109.28
|
| Rate for Payer: Kentucky WC Medicaid |
$3,188.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,525.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,773.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$131.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,219.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,076.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,883.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,342.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,984.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,332.68
|
| Rate for Payer: PHCS Commercial |
$8,810.69
|
| Rate for Payer: United Healthcare All Payer |
$8,076.46
|
|
|
DOXYCYCLINE 100mg BAG (ANES)
|
Facility
|
IP
|
$183.20
|
|
|
Service Code
|
NDC 68382091001
|
| Hospital Charge Code |
25004156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.96 |
| Max. Negotiated Rate |
$175.87 |
| Rate for Payer: Aetna Commercial |
$141.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.90
|
| Rate for Payer: Cash Price |
$91.60
|
| Rate for Payer: Cigna Commercial |
$152.06
|
| Rate for Payer: First Health Commercial |
$174.04
|
| Rate for Payer: Humana Commercial |
$155.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.22
|
| Rate for Payer: Ohio Health Group HMO |
$137.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$146.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.41
|
| Rate for Payer: PHCS Commercial |
$175.87
|
| Rate for Payer: United Healthcare All Payer |
$161.22
|
|
|
DOXYCYCLINE 100mg BAG (ANES)
|
Facility
|
OP
|
$183.20
|
|
|
Service Code
|
NDC 68382091001
|
| Hospital Charge Code |
25004156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.96 |
| Max. Negotiated Rate |
$175.87 |
| Rate for Payer: Aetna Commercial |
$141.06
|
| Rate for Payer: Anthem Medicaid |
$63.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.90
|
| Rate for Payer: Cash Price |
$91.60
|
| Rate for Payer: Cigna Commercial |
$152.06
|
| Rate for Payer: First Health Commercial |
$174.04
|
| Rate for Payer: Humana Commercial |
$155.72
|
| Rate for Payer: Humana KY Medicaid |
$63.00
|
| Rate for Payer: Kentucky WC Medicaid |
$63.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.22
|
| Rate for Payer: Ohio Health Group HMO |
$137.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$146.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.41
|
| Rate for Payer: PHCS Commercial |
$175.87
|
| Rate for Payer: United Healthcare All Payer |
$161.22
|
|
|
DOXY+NYST+HC Mouthwash 120mL
|
Facility
|
OP
|
$53.96
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
25004124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.19 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$41.55
|
| Rate for Payer: Anthem Medicaid |
$18.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.09
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cigna Commercial |
$44.79
|
| Rate for Payer: First Health Commercial |
$51.26
|
| Rate for Payer: Humana Commercial |
$45.87
|
| Rate for Payer: Humana KY Medicaid |
$18.56
|
| Rate for Payer: Kentucky WC Medicaid |
$18.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.48
|
| Rate for Payer: Ohio Health Group HMO |
$40.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.23
|
| Rate for Payer: PHCS Commercial |
$51.80
|
| Rate for Payer: United Healthcare All Payer |
$47.48
|
|
