|
GELFOAM 1 GRAM POWDER
|
Facility
|
IP
|
$155.90
|
|
|
Service Code
|
NDC 9043304
|
| Hospital Charge Code |
27000213
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$149.66 |
| Rate for Payer: Aetna Commercial |
$120.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.60
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cigna Commercial |
$129.40
|
| Rate for Payer: First Health Commercial |
$148.10
|
| Rate for Payer: Humana Commercial |
$132.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.19
|
| Rate for Payer: Ohio Health Group HMO |
$116.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.33
|
| Rate for Payer: PHCS Commercial |
$149.66
|
| Rate for Payer: United Healthcare All Payer |
$137.19
|
|
|
GELFOAM 1 GRAM POWDER
|
Facility
|
OP
|
$155.90
|
|
|
Service Code
|
NDC 9043304
|
| Hospital Charge Code |
27000213
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$149.66 |
| Rate for Payer: Aetna Commercial |
$120.04
|
| Rate for Payer: Anthem Medicaid |
$53.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.60
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cigna Commercial |
$129.40
|
| Rate for Payer: First Health Commercial |
$148.10
|
| Rate for Payer: Humana Commercial |
$132.52
|
| Rate for Payer: Humana KY Medicaid |
$53.61
|
| Rate for Payer: Kentucky WC Medicaid |
$54.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.19
|
| Rate for Payer: Ohio Health Group HMO |
$116.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.33
|
| Rate for Payer: PHCS Commercial |
$149.66
|
| Rate for Payer: United Healthcare All Payer |
$137.19
|
|
|
GELFOAM SIZE 100
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GELFOAM SIZE 100
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GELFOAM SIZE 50
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GELFOAM SIZE 50
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Facility
|
IP
|
$2,043.75
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
25004209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$265.69 |
| Max. Negotiated Rate |
$1,962.00 |
| Rate for Payer: Aetna Commercial |
$1,573.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,594.12
|
| Rate for Payer: Cash Price |
$1,021.88
|
| Rate for Payer: Cigna Commercial |
$1,696.31
|
| Rate for Payer: First Health Commercial |
$1,941.56
|
| Rate for Payer: Humana Commercial |
$1,737.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,675.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,508.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$613.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,798.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,532.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.56
|
| Rate for Payer: PHCS Commercial |
$1,962.00
|
| Rate for Payer: United Healthcare All Payer |
$1,798.50
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Facility
|
OP
|
$13.89
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
636T0161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$13.33 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Anthem Medicaid |
$4.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna Commercial |
$11.53
|
| Rate for Payer: First Health Commercial |
$13.20
|
| Rate for Payer: Humana Commercial |
$11.81
|
| Rate for Payer: Humana KY Medicaid |
$4.78
|
| Rate for Payer: Humana Medicare Advantage |
$0.49
|
| Rate for Payer: Kentucky WC Medicaid |
$4.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.22
|
| Rate for Payer: Ohio Health Group HMO |
$10.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.31
|
| Rate for Payer: PHCS Commercial |
$13.33
|
| Rate for Payer: United Healthcare All Payer |
$12.22
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Facility
|
OP
|
$2,043.75
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
25004209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1,962.00 |
| Rate for Payer: Aetna Commercial |
$1,573.69
|
| Rate for Payer: Anthem Medicaid |
$702.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,594.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1,021.88
|
| Rate for Payer: Cash Price |
$1,021.88
|
| Rate for Payer: Cigna Commercial |
$1,696.31
|
| Rate for Payer: First Health Commercial |
$1,941.56
|
| Rate for Payer: Humana Commercial |
$1,737.19
|
| Rate for Payer: Humana KY Medicaid |
$702.85
|
| Rate for Payer: Humana Medicare Advantage |
$0.49
|
| Rate for Payer: Kentucky WC Medicaid |
$710.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,675.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,508.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$716.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,798.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,532.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.56
|
| Rate for Payer: PHCS Commercial |
$1,962.00
|
| Rate for Payer: United Healthcare All Payer |
$1,798.50
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Professional
|
Both
|
$13.89
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
63600161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$13.89 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$13.89
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.09
|
| Rate for Payer: Multiplan PHCS |
$8.33
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$9.72
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Facility
|
OP
|
$13.89
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
63600161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$13.33 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Anthem Medicaid |
$4.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna Commercial |
$11.53
|
| Rate for Payer: First Health Commercial |
$13.20
|
| Rate for Payer: Humana Commercial |
$11.81
|
| Rate for Payer: Humana KY Medicaid |
$4.78
|
| Rate for Payer: Humana Medicare Advantage |
$0.49
|
| Rate for Payer: Kentucky WC Medicaid |
$4.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.22
|
| Rate for Payer: Ohio Health Group HMO |
$10.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.31
|
| Rate for Payer: PHCS Commercial |
$13.33
|
| Rate for Payer: United Healthcare All Payer |
$12.22
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Facility
|
IP
|
$13.89
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
63600161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$13.33 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.83
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna Commercial |
$11.53
|
| Rate for Payer: First Health Commercial |
$13.20
|
| Rate for Payer: Humana Commercial |
$11.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.22
|
| Rate for Payer: Ohio Health Group HMO |
$10.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.31
|
| Rate for Payer: PHCS Commercial |
$13.33
|
| Rate for Payer: United Healthcare All Payer |
$12.22
|
|
|
GELSYN-3 0.1mg(16.8mg) SYR
|
Facility
|
IP
|
$13.89
|
|
|
Service Code
|
HCPCS J7328
|
| Hospital Charge Code |
636T0161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$13.33 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.83
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna Commercial |
$11.53
|
| Rate for Payer: First Health Commercial |
$13.20
|
| Rate for Payer: Humana Commercial |
$11.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.22
|
| Rate for Payer: Ohio Health Group HMO |
$10.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.31
|
| Rate for Payer: PHCS Commercial |
$13.33
|
| Rate for Payer: United Healthcare All Payer |
$12.22
|
|
|
GEMZAR 1GM/26.3ML VIAL
|
Facility
|
IP
|
$246.89
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
25002619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$237.01 |
| Rate for Payer: Aetna Commercial |
$190.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.57
|
| Rate for Payer: Cash Price |
$123.44
|
| Rate for Payer: Cigna Commercial |
$204.92
|
| Rate for Payer: First Health Commercial |
$234.55
|
| Rate for Payer: Humana Commercial |
$209.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$202.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$182.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$217.26
|
| Rate for Payer: Ohio Health Group HMO |
$185.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.54
|
| Rate for Payer: PHCS Commercial |
$237.01
|
| Rate for Payer: United Healthcare All Payer |
$217.26
|
|
|
GEMZAR 1GM/26.3ML VIAL
|
Facility
|
OP
|
$246.89
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
25002619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$237.01 |
| Rate for Payer: Aetna Commercial |
$190.11
|
| Rate for Payer: Anthem Medicaid |
$84.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.57
|
| Rate for Payer: Cash Price |
$123.44
|
| Rate for Payer: Cigna Commercial |
$204.92
|
| Rate for Payer: First Health Commercial |
$234.55
|
| Rate for Payer: Humana Commercial |
$209.86
|
| Rate for Payer: Humana KY Medicaid |
$84.91
|
| Rate for Payer: Kentucky WC Medicaid |
$85.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$202.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$182.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$86.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$217.26
|
| Rate for Payer: Ohio Health Group HMO |
$185.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.54
|
| Rate for Payer: PHCS Commercial |
$237.01
|
| Rate for Payer: United Healthcare All Payer |
$217.26
|
|
|
GEMZAR 200MG (1G/50ML VIAL)
|
Facility
|
OP
|
$267.05
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
25002622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.72 |
| Max. Negotiated Rate |
$256.37 |
| Rate for Payer: Aetna Commercial |
$205.63
|
| Rate for Payer: Anthem Medicaid |
$91.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$208.30
|
| Rate for Payer: Cash Price |
$133.52
|
| Rate for Payer: Cigna Commercial |
$221.65
|
| Rate for Payer: First Health Commercial |
$253.70
|
| Rate for Payer: Humana Commercial |
$226.99
|
| Rate for Payer: Humana KY Medicaid |
$91.84
|
| Rate for Payer: Kentucky WC Medicaid |
$92.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$235.00
|
| Rate for Payer: Ohio Health Group HMO |
$200.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.79
|
| Rate for Payer: PHCS Commercial |
$256.37
|
| Rate for Payer: United Healthcare All Payer |
$235.00
|
|
|
GEMZAR 200MG (1G/50ML VIAL)
|
Facility
|
IP
|
$267.05
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
25002622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.72 |
| Max. Negotiated Rate |
$256.37 |
| Rate for Payer: Aetna Commercial |
$205.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$208.30
|
| Rate for Payer: Cash Price |
$133.52
|
| Rate for Payer: Cigna Commercial |
$221.65
|
| Rate for Payer: First Health Commercial |
$253.70
|
| Rate for Payer: Humana Commercial |
$226.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$235.00
|
| Rate for Payer: Ohio Health Group HMO |
$200.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.79
|
| Rate for Payer: PHCS Commercial |
$256.37
|
| Rate for Payer: United Healthcare All Payer |
$235.00
|
|
|
GEMZAR (GEMCITABINE) 200 MG C
|
Facility
|
IP
|
$65.40
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
25002621
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.01
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: First Health Commercial |
$62.13
|
| Rate for Payer: Humana Commercial |
$55.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.55
|
| Rate for Payer: Ohio Health Group HMO |
$49.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.27
|
| Rate for Payer: PHCS Commercial |
$62.78
|
| Rate for Payer: United Healthcare All Payer |
$57.55
|
|
|
GEMZAR (GEMCITABINE) 200 MG C
|
Facility
|
OP
|
$65.40
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
25002621
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Anthem Medicaid |
$22.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.01
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: First Health Commercial |
$62.13
|
| Rate for Payer: Humana Commercial |
$55.59
|
| Rate for Payer: Humana KY Medicaid |
$22.49
|
| Rate for Payer: Kentucky WC Medicaid |
$22.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.55
|
| Rate for Payer: Ohio Health Group HMO |
$49.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.27
|
| Rate for Payer: PHCS Commercial |
$62.78
|
| Rate for Payer: United Healthcare All Payer |
$57.55
|
|
|
GEN CEM FINNED TIB BASE LGE LT
|
Facility
|
IP
|
$8,786.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.18 |
| Max. Negotiated Rate |
$8,434.56 |
| Rate for Payer: Aetna Commercial |
$6,765.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.08
|
| Rate for Payer: Cash Price |
$4,393.00
|
| Rate for Payer: Cigna Commercial |
$7,292.38
|
| Rate for Payer: First Health Commercial |
$8,346.70
|
| Rate for Payer: Humana Commercial |
$7,468.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,204.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,635.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,731.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,142.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,723.66
|
| Rate for Payer: PHCS Commercial |
$8,434.56
|
| Rate for Payer: United Healthcare All Payer |
$7,731.68
|
|
|
GEN CEM FINNED TIB BASE LGE LT
|
Facility
|
OP
|
$8,786.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.18 |
| Max. Negotiated Rate |
$8,434.56 |
| Rate for Payer: Aetna Commercial |
$6,765.22
|
| Rate for Payer: Anthem Medicaid |
$3,021.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.08
|
| Rate for Payer: Cash Price |
$4,393.00
|
| Rate for Payer: Cigna Commercial |
$7,292.38
|
| Rate for Payer: First Health Commercial |
$8,346.70
|
| Rate for Payer: Humana Commercial |
$7,468.10
|
| Rate for Payer: Humana KY Medicaid |
$3,021.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,052.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,204.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,635.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,082.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,731.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,142.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,723.66
|
| Rate for Payer: PHCS Commercial |
$8,434.56
|
| Rate for Payer: United Healthcare All Payer |
$7,731.68
|
|
|
GEN CEM FINNED TIB BASE MAG LT
|
Facility
|
OP
|
$8,786.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.18 |
| Max. Negotiated Rate |
$8,434.56 |
| Rate for Payer: Aetna Commercial |
$6,765.22
|
| Rate for Payer: Anthem Medicaid |
$3,021.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.08
|
| Rate for Payer: Cash Price |
$4,393.00
|
| Rate for Payer: Cigna Commercial |
$7,292.38
|
| Rate for Payer: First Health Commercial |
$8,346.70
|
| Rate for Payer: Humana Commercial |
$7,468.10
|
| Rate for Payer: Humana KY Medicaid |
$3,021.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,052.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,204.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,635.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,082.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,731.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,142.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,723.66
|
| Rate for Payer: PHCS Commercial |
$8,434.56
|
| Rate for Payer: United Healthcare All Payer |
$7,731.68
|
|
|
GEN CEM FINNED TIB BASE MAG LT
|
Facility
|
IP
|
$8,786.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.18 |
| Max. Negotiated Rate |
$8,434.56 |
| Rate for Payer: Aetna Commercial |
$6,765.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.08
|
| Rate for Payer: Cash Price |
$4,393.00
|
| Rate for Payer: Cigna Commercial |
$7,292.38
|
| Rate for Payer: First Health Commercial |
$8,346.70
|
| Rate for Payer: Humana Commercial |
$7,468.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,204.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,635.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,731.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,142.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,723.66
|
| Rate for Payer: PHCS Commercial |
$8,434.56
|
| Rate for Payer: United Healthcare All Payer |
$7,731.68
|
|
|
GEN CEM FINNED TIB BASE MED LT
|
Facility
|
IP
|
$8,786.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.18 |
| Max. Negotiated Rate |
$8,434.56 |
| Rate for Payer: Aetna Commercial |
$6,765.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.08
|
| Rate for Payer: Cash Price |
$4,393.00
|
| Rate for Payer: Cigna Commercial |
$7,292.38
|
| Rate for Payer: First Health Commercial |
$8,346.70
|
| Rate for Payer: Humana Commercial |
$7,468.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,204.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,635.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,731.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,142.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,723.66
|
| Rate for Payer: PHCS Commercial |
$8,434.56
|
| Rate for Payer: United Healthcare All Payer |
$7,731.68
|
|
|
GEN CEM FINNED TIB BASE MED LT
|
Facility
|
OP
|
$8,786.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.18 |
| Max. Negotiated Rate |
$8,434.56 |
| Rate for Payer: Aetna Commercial |
$6,765.22
|
| Rate for Payer: Anthem Medicaid |
$3,021.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.08
|
| Rate for Payer: Cash Price |
$4,393.00
|
| Rate for Payer: Cigna Commercial |
$7,292.38
|
| Rate for Payer: First Health Commercial |
$8,346.70
|
| Rate for Payer: Humana Commercial |
$7,468.10
|
| Rate for Payer: Humana KY Medicaid |
$3,021.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,052.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,204.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,635.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,082.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,731.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,142.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,723.66
|
| Rate for Payer: PHCS Commercial |
$8,434.56
|
| Rate for Payer: United Healthcare All Payer |
$7,731.68
|
|
