|
DUCTOGRAM SINGLE DUCT S&I(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
402P0085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$22.39 |
| Max. Negotiated Rate |
$149.83 |
| Rate for Payer: Aetna Commercial |
$118.33
|
| Rate for Payer: Ambetter Exchange |
$48.60
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$48.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$48.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$58.32
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$149.83
|
| Rate for Payer: Healthspan PPO |
$110.88
|
| Rate for Payer: Humana Medicaid |
$70.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$48.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.91
|
| Rate for Payer: Molina Healthcare Passport |
$70.50
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.18
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.20
|
| Rate for Payer: Wellcare Medicare Advantage |
$48.60
|
|
|
DUCTOGRAM SINGLE DUCT S&I(T
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
402T0085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$206.68 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem Medicaid |
$206.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Humana KY Medicaid |
$206.68
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.69
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
DUCTOGRAM SINGLE DUCT S&I(T
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
402T0085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$180.30 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.69
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
DULCOLAX (BISACODYL) 5MG/1TAB
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 904640761
|
| Hospital Charge Code |
25000582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
DULCOLAX (BISACODYL) 5MG/1TAB
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 904640761
|
| Hospital Charge Code |
25000582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
DUODENOTOMY - FOR EXPLORATION
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
76101803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$490.98 |
| Max. Negotiated Rate |
$1,240.43 |
| Rate for Payer: Aetna Commercial |
$1,240.43
|
| Rate for Payer: Ambetter Exchange |
$799.73
|
| Rate for Payer: Anthem Medicaid |
$490.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$799.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$799.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$959.68
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,147.34
|
| Rate for Payer: Healthspan PPO |
$1,046.07
|
| Rate for Payer: Humana Medicaid |
$490.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,103.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$799.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$799.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$500.80
|
| Rate for Payer: Molina Healthcare Passport |
$490.98
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,039.65
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$495.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$799.73
|
|
|
DUODENOTOMY - FOR EXPLORATION
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
76101803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$555.00 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem Medicaid |
$636.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Humana KY Medicaid |
$636.22
|
| Rate for Payer: Kentucky WC Medicaid |
$642.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$648.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,609.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
DUODENOTOMY - FOR EXPLORATION
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
76101803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$555.00 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,609.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
DUODENOTOMY - FOR EXPLORATIO(P
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
761P1803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$490.98 |
| Max. Negotiated Rate |
$1,240.43 |
| Rate for Payer: Aetna Commercial |
$1,240.43
|
| Rate for Payer: Ambetter Exchange |
$799.73
|
| Rate for Payer: Anthem Medicaid |
$490.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$799.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$799.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$959.68
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,147.34
|
| Rate for Payer: Healthspan PPO |
$1,046.07
|
| Rate for Payer: Humana Medicaid |
$490.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,103.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$799.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$799.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$500.80
|
| Rate for Payer: Molina Healthcare Passport |
$490.98
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,039.65
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$495.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$799.73
|
|
|
DUONEB NEB [3 ML]
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
25003033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
DUONEB NEB [3 ML]
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
25003033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
DUOVISC 0.55-0.5ML KIT
|
Facility
|
IP
|
$855.61
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004416
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$256.68 |
| Max. Negotiated Rate |
$821.39 |
| Rate for Payer: Aetna Commercial |
$658.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$667.38
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$710.16
|
| Rate for Payer: First Health Commercial |
$812.83
|
| Rate for Payer: Humana Commercial |
$727.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$701.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$631.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$752.94
|
| Rate for Payer: Ohio Health Group HMO |
$641.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$684.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$744.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.37
|
| Rate for Payer: PHCS Commercial |
$821.39
|
| Rate for Payer: United Healthcare All Payer |
$752.94
|
|
|
DUOVISC 0.55-0.5ML KIT
|
Facility
|
OP
|
$855.61
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004416
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$256.68 |
| Max. Negotiated Rate |
$821.39 |
| Rate for Payer: Aetna Commercial |
$658.82
|
| Rate for Payer: Anthem Medicaid |
$294.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$667.38
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$710.16
|
| Rate for Payer: First Health Commercial |
$812.83
|
| Rate for Payer: Humana Commercial |
$727.27
|
| Rate for Payer: Humana KY Medicaid |
$294.24
|
| Rate for Payer: Kentucky WC Medicaid |
$297.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$701.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$631.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$300.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$752.94
|
| Rate for Payer: Ohio Health Group HMO |
$641.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$684.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$744.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.37
|
| Rate for Payer: PHCS Commercial |
$821.39
|
| Rate for Payer: United Healthcare All Payer |
$752.94
|
|
|
DUOVISC 0.5mL/0.85mL KIT
|
Facility
|
OP
|
$895.49
|
|
|
Service Code
|
NDC 8065199907
|
| Hospital Charge Code |
25004423
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.65 |
| Max. Negotiated Rate |
$859.67 |
| Rate for Payer: Aetna Commercial |
$689.53
|
| Rate for Payer: Anthem Medicaid |
$307.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$698.48
|
| Rate for Payer: Cash Price |
$447.74
|
| Rate for Payer: Cigna Commercial |
$743.26
|
| Rate for Payer: First Health Commercial |
$850.72
|
| Rate for Payer: Humana Commercial |
$761.17
|
| Rate for Payer: Humana KY Medicaid |
$307.96
|
| Rate for Payer: Kentucky WC Medicaid |
$311.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$734.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$660.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$314.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$788.03
|
| Rate for Payer: Ohio Health Group HMO |
$671.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$716.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$779.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$617.89
|
| Rate for Payer: PHCS Commercial |
$859.67
|
| Rate for Payer: United Healthcare All Payer |
$788.03
|
|
|
DUOVISC 0.5mL/0.85mL KIT
|
Facility
|
IP
|
$895.49
|
|
|
Service Code
|
NDC 8065199907
|
| Hospital Charge Code |
25004423
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.65 |
| Max. Negotiated Rate |
$859.67 |
| Rate for Payer: Aetna Commercial |
$689.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$698.48
|
| Rate for Payer: Cash Price |
$447.74
|
| Rate for Payer: Cigna Commercial |
$743.26
|
| Rate for Payer: First Health Commercial |
$850.72
|
| Rate for Payer: Humana Commercial |
$761.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$734.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$660.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$788.03
|
| Rate for Payer: Ohio Health Group HMO |
$671.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$716.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$779.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$617.89
|
| Rate for Payer: PHCS Commercial |
$859.67
|
| Rate for Payer: United Healthcare All Payer |
$788.03
|
|
|
DUPIXENT 200mg SYRINGE
|
Facility
|
OP
|
$10,881.91
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,264.57 |
| Max. Negotiated Rate |
$10,446.63 |
| Rate for Payer: Aetna Commercial |
$8,379.07
|
| Rate for Payer: Anthem Medicaid |
$3,742.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,487.89
|
| Rate for Payer: Cash Price |
$5,440.96
|
| Rate for Payer: Cigna Commercial |
$9,031.99
|
| Rate for Payer: First Health Commercial |
$10,337.81
|
| Rate for Payer: Humana Commercial |
$9,249.62
|
| Rate for Payer: Humana KY Medicaid |
$3,742.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,780.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,923.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,030.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,264.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,817.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,576.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,161.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,705.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,467.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,508.52
|
| Rate for Payer: PHCS Commercial |
$10,446.63
|
| Rate for Payer: United Healthcare All Payer |
$9,576.08
|
|
|
DUPIXENT 200mg SYRINGE
|
Facility
|
IP
|
$10,881.91
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,264.57 |
| Max. Negotiated Rate |
$10,446.63 |
| Rate for Payer: Aetna Commercial |
$8,379.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,487.89
|
| Rate for Payer: Cash Price |
$5,440.96
|
| Rate for Payer: Cigna Commercial |
$9,031.99
|
| Rate for Payer: First Health Commercial |
$10,337.81
|
| Rate for Payer: Humana Commercial |
$9,249.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,923.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,030.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,264.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,576.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,161.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,705.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,467.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,508.52
|
| Rate for Payer: PHCS Commercial |
$10,446.63
|
| Rate for Payer: United Healthcare All Payer |
$9,576.08
|
|
|
DUPIXENT 300mg SYRINGE
|
Facility
|
IP
|
$10,881.91
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,264.57 |
| Max. Negotiated Rate |
$10,446.63 |
| Rate for Payer: Aetna Commercial |
$8,379.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,487.89
|
| Rate for Payer: Cash Price |
$5,440.96
|
| Rate for Payer: Cigna Commercial |
$9,031.99
|
| Rate for Payer: First Health Commercial |
$10,337.81
|
| Rate for Payer: Humana Commercial |
$9,249.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,923.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,030.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,264.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,576.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,161.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,705.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,467.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,508.52
|
| Rate for Payer: PHCS Commercial |
$10,446.63
|
| Rate for Payer: United Healthcare All Payer |
$9,576.08
|
|
|
DUPIXENT 300mg SYRINGE
|
Facility
|
OP
|
$10,881.91
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,264.57 |
| Max. Negotiated Rate |
$10,446.63 |
| Rate for Payer: Aetna Commercial |
$8,379.07
|
| Rate for Payer: Anthem Medicaid |
$3,742.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,487.89
|
| Rate for Payer: Cash Price |
$5,440.96
|
| Rate for Payer: Cigna Commercial |
$9,031.99
|
| Rate for Payer: First Health Commercial |
$10,337.81
|
| Rate for Payer: Humana Commercial |
$9,249.62
|
| Rate for Payer: Humana KY Medicaid |
$3,742.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,780.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,923.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,030.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,264.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,817.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,576.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,161.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,705.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,467.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,508.52
|
| Rate for Payer: PHCS Commercial |
$10,446.63
|
| Rate for Payer: United Healthcare All Payer |
$9,576.08
|
|
|
DUPLEX COMPLETE
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS 93970
|
| Hospital Charge Code |
92100023
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$1,268.16 |
| Rate for Payer: Aetna Commercial |
$1,017.17
|
| Rate for Payer: Anthem Medicaid |
$454.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,030.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$660.50
|
| Rate for Payer: Cash Price |
$660.50
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,254.95
|
| Rate for Payer: Humana Commercial |
$1,122.85
|
| Rate for Payer: Humana KY Medicaid |
$454.29
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$458.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,083.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$974.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$463.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,162.48
|
| Rate for Payer: Ohio Health Group HMO |
$990.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,056.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,149.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$911.49
|
| Rate for Payer: PHCS Commercial |
$1,268.16
|
| Rate for Payer: United Healthcare All Payer |
$1,162.48
|
|
|
DUPLEX COMPLETE
|
Professional
|
Both
|
$1,321.00
|
|
|
Service Code
|
HCPCS 93970
|
| Hospital Charge Code |
92100023
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$46.44 |
| Max. Negotiated Rate |
$792.60 |
| Rate for Payer: Aetna Commercial |
$288.23
|
| Rate for Payer: Ambetter Exchange |
$165.29
|
| Rate for Payer: Anthem Medicaid |
$171.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$165.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$165.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$198.35
|
| Rate for Payer: Cash Price |
$660.50
|
| Rate for Payer: Cash Price |
$660.50
|
| Rate for Payer: Cigna Commercial |
$314.83
|
| Rate for Payer: Healthspan PPO |
$307.89
|
| Rate for Payer: Humana Medicaid |
$171.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$165.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.21
|
| Rate for Payer: Molina Healthcare Passport |
$171.77
|
| Rate for Payer: Multiplan PHCS |
$792.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$214.88
|
| Rate for Payer: UHCCP Medicaid |
$462.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$173.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$165.29
|
|
|
DUPLEX COMPLETE
|
Facility
|
IP
|
$1,206.00
|
|
|
Service Code
|
HCPCS 93970
|
| Hospital Charge Code |
92000009
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$361.80 |
| Max. Negotiated Rate |
$1,157.76 |
| Rate for Payer: Aetna Commercial |
$928.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$940.68
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cigna Commercial |
$1,000.98
|
| Rate for Payer: First Health Commercial |
$1,145.70
|
| Rate for Payer: Humana Commercial |
$1,025.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$988.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$890.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$361.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,061.28
|
| Rate for Payer: Ohio Health Group HMO |
$904.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$964.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,049.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$832.14
|
| Rate for Payer: PHCS Commercial |
$1,157.76
|
| Rate for Payer: United Healthcare All Payer |
$1,061.28
|
|
|
DUPLEX COMPLETE
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS 93970
|
| Hospital Charge Code |
92100023
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$396.30 |
| Max. Negotiated Rate |
$1,268.16 |
| Rate for Payer: Aetna Commercial |
$1,017.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,030.38
|
| Rate for Payer: Cash Price |
$660.50
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,254.95
|
| Rate for Payer: Humana Commercial |
$1,122.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,083.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$974.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$396.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,162.48
|
| Rate for Payer: Ohio Health Group HMO |
$990.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,056.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,149.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$911.49
|
| Rate for Payer: PHCS Commercial |
$1,268.16
|
| Rate for Payer: United Healthcare All Payer |
$1,162.48
|
|
|
DUPLEX COMPLETE
|
Professional
|
Both
|
$1,364.00
|
|
|
Service Code
|
HCPCS 93970
|
| Hospital Charge Code |
92100011
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$46.44 |
| Max. Negotiated Rate |
$818.40 |
| Rate for Payer: Aetna Commercial |
$288.23
|
| Rate for Payer: Ambetter Exchange |
$165.29
|
| Rate for Payer: Anthem Medicaid |
$171.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$165.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$165.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$198.35
|
| Rate for Payer: Cash Price |
$682.00
|
| Rate for Payer: Cash Price |
$682.00
|
| Rate for Payer: Cigna Commercial |
$314.83
|
| Rate for Payer: Healthspan PPO |
$307.89
|
| Rate for Payer: Humana Medicaid |
$171.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$165.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.21
|
| Rate for Payer: Molina Healthcare Passport |
$171.77
|
| Rate for Payer: Multiplan PHCS |
$818.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$214.88
|
| Rate for Payer: UHCCP Medicaid |
$477.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$173.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$165.29
|
|
|
DUPLEX COMPLETE
|
Facility
|
OP
|
$1,206.00
|
|
|
Service Code
|
HCPCS 93970
|
| Hospital Charge Code |
92000009
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$1,157.76 |
| Rate for Payer: Aetna Commercial |
$928.62
|
| Rate for Payer: Anthem Medicaid |
$414.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$940.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cigna Commercial |
$1,000.98
|
| Rate for Payer: First Health Commercial |
$1,145.70
|
| Rate for Payer: Humana Commercial |
$1,025.10
|
| Rate for Payer: Humana KY Medicaid |
$414.74
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$418.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$988.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$890.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$423.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,061.28
|
| Rate for Payer: Ohio Health Group HMO |
$904.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$964.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,049.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$832.14
|
| Rate for Payer: PHCS Commercial |
$1,157.76
|
| Rate for Payer: United Healthcare All Payer |
$1,061.28
|
|
