|
FLUCONAZOLE 400MG/200ML IVPB
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
25002064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Anthem Medicaid |
$41.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.38
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Humana KY Medicaid |
$41.61
|
| Rate for Payer: Kentucky WC Medicaid |
$42.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.51
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
| Rate for Payer: Aetna Commercial |
$93.17
|
|
|
FLUCYTOSINE 500 MG CAPSULE
|
Facility
|
IP
|
$328.81
|
|
|
Service Code
|
NDC 42494034001
|
| Hospital Charge Code |
25004093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.75 |
| Max. Negotiated Rate |
$315.66 |
| Rate for Payer: Aetna Commercial |
$253.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.47
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$272.91
|
| Rate for Payer: First Health Commercial |
$312.37
|
| Rate for Payer: Humana Commercial |
$279.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.35
|
| Rate for Payer: Ohio Health Group HMO |
$246.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.93
|
| Rate for Payer: PHCS Commercial |
$315.66
|
| Rate for Payer: United Healthcare All Payer |
$289.35
|
|
|
FLUCYTOSINE 500 MG CAPSULE
|
Facility
|
OP
|
$328.81
|
|
|
Service Code
|
NDC 42494034001
|
| Hospital Charge Code |
25004093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.75 |
| Max. Negotiated Rate |
$315.66 |
| Rate for Payer: Aetna Commercial |
$253.18
|
| Rate for Payer: Anthem Medicaid |
$113.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.47
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$272.91
|
| Rate for Payer: First Health Commercial |
$312.37
|
| Rate for Payer: Humana Commercial |
$279.49
|
| Rate for Payer: Humana KY Medicaid |
$113.08
|
| Rate for Payer: Kentucky WC Medicaid |
$114.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.35
|
| Rate for Payer: Ohio Health Group HMO |
$246.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.93
|
| Rate for Payer: PHCS Commercial |
$315.66
|
| Rate for Payer: United Healthcare All Payer |
$289.35
|
|
|
FLUDARA(FLUDARABINE) 50MG/2ML
|
Facility
|
IP
|
$1,481.75
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
25002615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.63 |
| Max. Negotiated Rate |
$1,422.48 |
| Rate for Payer: Aetna Commercial |
$1,140.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,155.76
|
| Rate for Payer: Cash Price |
$740.88
|
| Rate for Payer: Cigna Commercial |
$1,229.85
|
| Rate for Payer: First Health Commercial |
$1,407.66
|
| Rate for Payer: Humana Commercial |
$1,259.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,215.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,093.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$444.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,303.94
|
| Rate for Payer: Ohio Health Group HMO |
$1,111.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$459.34
|
| Rate for Payer: PHCS Commercial |
$1,422.48
|
| Rate for Payer: United Healthcare All Payer |
$1,303.94
|
|
|
FLUDARA(FLUDARABINE) 50MG/2ML
|
Facility
|
OP
|
$1,481.75
|
|
|
Service Code
|
HCPCS J9185
|
| Hospital Charge Code |
25002615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.97 |
| Max. Negotiated Rate |
$1,422.48 |
| Rate for Payer: Aetna Commercial |
$1,140.95
|
| Rate for Payer: Anthem Medicaid |
$509.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,155.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$243.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$234.86
|
| Rate for Payer: Cash Price |
$740.88
|
| Rate for Payer: Cash Price |
$740.88
|
| Rate for Payer: Cigna Commercial |
$1,229.85
|
| Rate for Payer: First Health Commercial |
$1,407.66
|
| Rate for Payer: Humana Commercial |
$1,259.49
|
| Rate for Payer: Humana KY Medicaid |
$509.57
|
| Rate for Payer: Humana Medicare Advantage |
$173.97
|
| Rate for Payer: Kentucky WC Medicaid |
$514.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,215.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,093.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$208.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$519.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,303.94
|
| Rate for Payer: Ohio Health Group HMO |
$1,111.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$459.34
|
| Rate for Payer: PHCS Commercial |
$1,422.48
|
| Rate for Payer: United Healthcare All Payer |
$1,303.94
|
|
|
FLUID CELL COUNT
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
30001538
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.96 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$70.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.88
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: First Health Commercial |
$87.40
|
| Rate for Payer: Humana Commercial |
$78.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.96
|
| Rate for Payer: Ohio Health Group HMO |
$69.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.52
|
| Rate for Payer: PHCS Commercial |
$88.32
|
| Rate for Payer: United Healthcare All Payer |
$80.96
|
|
|
FLUID CELL COUNT
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
30001538
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$70.84
|
| Rate for Payer: Anthem Medicaid |
$5.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: First Health Commercial |
$87.40
|
| Rate for Payer: Humana Commercial |
$78.20
|
| Rate for Payer: Humana KY Medicaid |
$5.60
|
| Rate for Payer: Humana Medicare Advantage |
$5.60
|
| Rate for Payer: Kentucky WC Medicaid |
$5.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.96
|
| Rate for Payer: Ohio Health Group HMO |
$69.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.52
|
| Rate for Payer: PHCS Commercial |
$88.32
|
| Rate for Payer: United Healthcare All Payer |
$80.96
|
|
|
FLUID CHOLESTEROL
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 84311
|
| Hospital Charge Code |
30000516
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.11 |
| Max. Negotiated Rate |
$141.12 |
| Rate for Payer: Aetna Commercial |
$113.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.04
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$122.01
|
| Rate for Payer: First Health Commercial |
$139.65
|
| Rate for Payer: Humana Commercial |
$124.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.36
|
| Rate for Payer: Ohio Health Group HMO |
$110.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.57
|
| Rate for Payer: PHCS Commercial |
$141.12
|
| Rate for Payer: United Healthcare All Payer |
$129.36
|
|
|
FLUID CHOLESTEROL
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 84311
|
| Hospital Charge Code |
30000516
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$141.12 |
| Rate for Payer: Aetna Commercial |
$113.19
|
| Rate for Payer: Anthem Medicaid |
$8.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.10
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$122.01
|
| Rate for Payer: First Health Commercial |
$139.65
|
| Rate for Payer: Humana Commercial |
$124.95
|
| Rate for Payer: Humana KY Medicaid |
$8.10
|
| Rate for Payer: Humana Medicare Advantage |
$8.10
|
| Rate for Payer: Kentucky WC Medicaid |
$8.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.36
|
| Rate for Payer: Ohio Health Group HMO |
$110.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.57
|
| Rate for Payer: PHCS Commercial |
$141.12
|
| Rate for Payer: United Healthcare All Payer |
$129.36
|
|
|
FLUID CREATININE
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS 82570
|
| Hospital Charge Code |
30001830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem Medicaid |
$5.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.18
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Humana KY Medicaid |
$5.18
|
| Rate for Payer: Humana Medicare Advantage |
$5.18
|
| Rate for Payer: Kentucky WC Medicaid |
$5.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.67
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
FLUID CREATININE
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS 82570
|
| Hospital Charge Code |
30001830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.77
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.67
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
FLUID PH
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS 83986
|
| Hospital Charge Code |
30000466
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$42.24 |
| Rate for Payer: Aetna Commercial |
$33.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.33
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cigna Commercial |
$36.52
|
| Rate for Payer: First Health Commercial |
$41.80
|
| Rate for Payer: Humana Commercial |
$37.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$38.72
|
| Rate for Payer: Ohio Health Group HMO |
$33.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.64
|
| Rate for Payer: PHCS Commercial |
$42.24
|
| Rate for Payer: United Healthcare All Payer |
$38.72
|
|
|
FLUID PH
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS 83986
|
| Hospital Charge Code |
30000466
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$42.24 |
| Rate for Payer: Aetna Commercial |
$33.88
|
| Rate for Payer: Anthem Medicaid |
$3.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.33
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.58
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cigna Commercial |
$36.52
|
| Rate for Payer: First Health Commercial |
$41.80
|
| Rate for Payer: Humana Commercial |
$37.40
|
| Rate for Payer: Humana KY Medicaid |
$3.58
|
| Rate for Payer: Humana Medicare Advantage |
$3.58
|
| Rate for Payer: Kentucky WC Medicaid |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$38.72
|
| Rate for Payer: Ohio Health Group HMO |
$33.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.64
|
| Rate for Payer: PHCS Commercial |
$42.24
|
| Rate for Payer: United Healthcare All Payer |
$38.72
|
|
|
FLUID PROTEIN
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS 84157
|
| Hospital Charge Code |
30000495
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.87
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
FLUID PROTEIN
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS 84157
|
| Hospital Charge Code |
30000495
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem Medicaid |
$4.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.00
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Humana KY Medicaid |
$4.00
|
| Rate for Payer: Humana Medicare Advantage |
$4.00
|
| Rate for Payer: Kentucky WC Medicaid |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.87
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
FLUID TRIGLYCERIDE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 84478
|
| Hospital Charge Code |
30000541
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.32
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
FLUID TRIGLYCERIDE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 84478
|
| Hospital Charge Code |
30000541
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$5.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.74
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.74
|
| Rate for Payer: Kentucky WC Medicaid |
$5.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.32
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
FLUMIST QUAD 23-24 SPRAY
|
Facility
|
OP
|
$125.75
|
|
|
Service Code
|
HCPCS 90672
|
| Hospital Charge Code |
770T0026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$120.72 |
| Rate for Payer: Aetna Commercial |
$96.83
|
| Rate for Payer: Anthem Medicaid |
$43.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.08
|
| Rate for Payer: Cash Price |
$62.88
|
| Rate for Payer: Cigna Commercial |
$104.37
|
| Rate for Payer: First Health Commercial |
$119.46
|
| Rate for Payer: Humana Commercial |
$106.89
|
| Rate for Payer: Humana KY Medicaid |
$43.25
|
| Rate for Payer: Kentucky WC Medicaid |
$43.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.66
|
| Rate for Payer: Ohio Health Group HMO |
$94.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.98
|
| Rate for Payer: PHCS Commercial |
$120.72
|
| Rate for Payer: United Healthcare All Payer |
$110.66
|
|
|
FLUMIST QUAD 23-24 SPRAY
|
Facility
|
OP
|
$125.75
|
|
|
Service Code
|
HCPCS 90672
|
| Hospital Charge Code |
77000026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$120.72 |
| Rate for Payer: Aetna Commercial |
$96.83
|
| Rate for Payer: Anthem Medicaid |
$43.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.08
|
| Rate for Payer: Cash Price |
$62.88
|
| Rate for Payer: Cigna Commercial |
$104.37
|
| Rate for Payer: First Health Commercial |
$119.46
|
| Rate for Payer: Humana Commercial |
$106.89
|
| Rate for Payer: Humana KY Medicaid |
$43.25
|
| Rate for Payer: Kentucky WC Medicaid |
$43.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.66
|
| Rate for Payer: Ohio Health Group HMO |
$94.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.98
|
| Rate for Payer: PHCS Commercial |
$120.72
|
| Rate for Payer: United Healthcare All Payer |
$110.66
|
|
|
FLUMIST QUAD 23-24 SPRAY
|
Facility
|
IP
|
$125.75
|
|
|
Service Code
|
HCPCS 90672
|
| Hospital Charge Code |
77000026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$120.72 |
| Rate for Payer: Aetna Commercial |
$96.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.08
|
| Rate for Payer: Cash Price |
$62.88
|
| Rate for Payer: Cigna Commercial |
$104.37
|
| Rate for Payer: First Health Commercial |
$119.46
|
| Rate for Payer: Humana Commercial |
$106.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.66
|
| Rate for Payer: Ohio Health Group HMO |
$94.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.98
|
| Rate for Payer: PHCS Commercial |
$120.72
|
| Rate for Payer: United Healthcare All Payer |
$110.66
|
|
|
FLUMIST QUAD 23-24 SPRAY
|
Facility
|
IP
|
$125.75
|
|
|
Service Code
|
HCPCS 90672
|
| Hospital Charge Code |
770T0026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$120.72 |
| Rate for Payer: Aetna Commercial |
$96.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.08
|
| Rate for Payer: Cash Price |
$62.88
|
| Rate for Payer: Cigna Commercial |
$104.37
|
| Rate for Payer: First Health Commercial |
$119.46
|
| Rate for Payer: Humana Commercial |
$106.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.66
|
| Rate for Payer: Ohio Health Group HMO |
$94.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.98
|
| Rate for Payer: PHCS Commercial |
$120.72
|
| Rate for Payer: United Healthcare All Payer |
$110.66
|
|
|
FLUMIST QUAD 23-24 SPRAY
|
Professional
|
Both
|
$125.75
|
|
|
Service Code
|
HCPCS 90672
|
| Hospital Charge Code |
77000026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$125.75 |
| Rate for Payer: Buckeye Medicare Advantage |
$125.75
|
| Rate for Payer: Cash Price |
$62.88
|
| Rate for Payer: Cash Price |
$62.88
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$39.05
|
| Rate for Payer: Multiplan PHCS |
$75.45
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.02
|
| Rate for Payer: UHCCP Medicaid |
$44.01
|
|
|
FLUOCINONIDE-E 0.05% CRM 30GM
|
Facility
|
OP
|
$10.40
|
|
|
Service Code
|
NDC 51672125402
|
| Hospital Charge Code |
25003899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: Humana Commercial |
$8.84
|
| Rate for Payer: Humana KY Medicaid |
$3.58
|
| Rate for Payer: Kentucky WC Medicaid |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.15
|
| Rate for Payer: Ohio Health Group HMO |
$7.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$9.98
|
| Rate for Payer: United Healthcare All Payer |
$9.15
|
| Rate for Payer: Aetna Commercial |
$8.01
|
| Rate for Payer: Anthem Medicaid |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.11
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna Commercial |
$8.63
|
| Rate for Payer: First Health Commercial |
$9.88
|
|
|
FLUOCINONIDE-E 0.05% CRM 30GM
|
Facility
|
IP
|
$10.40
|
|
|
Service Code
|
NDC 51672125402
|
| Hospital Charge Code |
25003899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: Aetna Commercial |
$8.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.11
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna Commercial |
$8.63
|
| Rate for Payer: First Health Commercial |
$9.88
|
| Rate for Payer: Humana Commercial |
$8.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.15
|
| Rate for Payer: Ohio Health Group HMO |
$7.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$9.98
|
| Rate for Payer: United Healthcare All Payer |
$9.15
|
|
|
FLUORESCITE 10% 5 ML 500MG/5ML
|
Facility
|
OP
|
$341.00
|
|
|
Service Code
|
NDC 17478025310
|
| Hospital Charge Code |
25003072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.33 |
| Max. Negotiated Rate |
$327.36 |
| Rate for Payer: Aetna Commercial |
$262.57
|
| Rate for Payer: Anthem Medicaid |
$117.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.98
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Cigna Commercial |
$283.03
|
| Rate for Payer: First Health Commercial |
$323.95
|
| Rate for Payer: Humana Commercial |
$289.85
|
| Rate for Payer: Humana KY Medicaid |
$117.27
|
| Rate for Payer: Kentucky WC Medicaid |
$118.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$279.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$251.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$119.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$300.08
|
| Rate for Payer: Ohio Health Group HMO |
$255.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.71
|
| Rate for Payer: PHCS Commercial |
$327.36
|
| Rate for Payer: United Healthcare All Payer |
$300.08
|
|
