|
GENTAMICIN 340MG/108.5ML D5W
|
Facility
|
OP
|
$126.40
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.43 |
| Max. Negotiated Rate |
$121.34 |
| Rate for Payer: Aetna Commercial |
$97.33
|
| Rate for Payer: Anthem Medicaid |
$43.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.59
|
| Rate for Payer: Cash Price |
$63.20
|
| Rate for Payer: Cigna Commercial |
$104.91
|
| Rate for Payer: First Health Commercial |
$120.08
|
| Rate for Payer: Humana Commercial |
$107.44
|
| Rate for Payer: Humana KY Medicaid |
$43.47
|
| Rate for Payer: Kentucky WC Medicaid |
$43.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.23
|
| Rate for Payer: Ohio Health Group HMO |
$94.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.18
|
| Rate for Payer: PHCS Commercial |
$121.34
|
| Rate for Payer: United Healthcare All Payer |
$111.23
|
|
|
GENTAMICIN 340MG/108.5ML D5W
|
Facility
|
IP
|
$126.40
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.43 |
| Max. Negotiated Rate |
$121.34 |
| Rate for Payer: Aetna Commercial |
$97.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.59
|
| Rate for Payer: Cash Price |
$63.20
|
| Rate for Payer: Cigna Commercial |
$104.91
|
| Rate for Payer: First Health Commercial |
$120.08
|
| Rate for Payer: Humana Commercial |
$107.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.23
|
| Rate for Payer: Ohio Health Group HMO |
$94.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.18
|
| Rate for Payer: PHCS Commercial |
$121.34
|
| Rate for Payer: United Healthcare All Payer |
$111.23
|
|
|
GENTAMICIN 400MG/110ML IN D5/W
|
Facility
|
OP
|
$129.45
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$124.27 |
| Rate for Payer: Aetna Commercial |
$99.68
|
| Rate for Payer: Anthem Medicaid |
$44.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.97
|
| Rate for Payer: Cash Price |
$64.72
|
| Rate for Payer: Cigna Commercial |
$107.44
|
| Rate for Payer: First Health Commercial |
$122.98
|
| Rate for Payer: Humana Commercial |
$110.03
|
| Rate for Payer: Humana KY Medicaid |
$44.52
|
| Rate for Payer: Kentucky WC Medicaid |
$44.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.92
|
| Rate for Payer: Ohio Health Group HMO |
$97.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.13
|
| Rate for Payer: PHCS Commercial |
$124.27
|
| Rate for Payer: United Healthcare All Payer |
$113.92
|
|
|
GENTAMICIN 400MG/110ML IN D5/W
|
Facility
|
IP
|
$129.45
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$124.27 |
| Rate for Payer: Aetna Commercial |
$99.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.97
|
| Rate for Payer: Cash Price |
$64.72
|
| Rate for Payer: Cigna Commercial |
$107.44
|
| Rate for Payer: First Health Commercial |
$122.98
|
| Rate for Payer: Humana Commercial |
$110.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.92
|
| Rate for Payer: Ohio Health Group HMO |
$97.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.13
|
| Rate for Payer: PHCS Commercial |
$124.27
|
| Rate for Payer: United Healthcare All Payer |
$113.92
|
|
|
Gentamicin 80mg(100mg IVPB)ANE
|
Facility
|
IP
|
$112.09
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.61 |
| Rate for Payer: Aetna Commercial |
$86.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.43
|
| Rate for Payer: Cash Price |
$56.05
|
| Rate for Payer: Cigna Commercial |
$93.03
|
| Rate for Payer: First Health Commercial |
$106.49
|
| Rate for Payer: Humana Commercial |
$95.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.64
|
| Rate for Payer: Ohio Health Group HMO |
$84.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.75
|
| Rate for Payer: PHCS Commercial |
$107.61
|
| Rate for Payer: United Healthcare All Payer |
$98.64
|
|
|
Gentamicin 80mg(100mg IVPB)ANE
|
Facility
|
OP
|
$112.09
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.61 |
| Rate for Payer: Aetna Commercial |
$86.31
|
| Rate for Payer: Anthem Medicaid |
$38.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.43
|
| Rate for Payer: Cash Price |
$56.05
|
| Rate for Payer: Cigna Commercial |
$93.03
|
| Rate for Payer: First Health Commercial |
$106.49
|
| Rate for Payer: Humana Commercial |
$95.28
|
| Rate for Payer: Humana KY Medicaid |
$38.55
|
| Rate for Payer: Kentucky WC Medicaid |
$38.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.64
|
| Rate for Payer: Ohio Health Group HMO |
$84.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.75
|
| Rate for Payer: PHCS Commercial |
$107.61
|
| Rate for Payer: United Healthcare All Payer |
$98.64
|
|
|
GENTAMICIN 80 MG [140MG SYR]
|
Facility
|
IP
|
$116.93
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$112.25 |
| Rate for Payer: Aetna Commercial |
$90.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.21
|
| Rate for Payer: Cash Price |
$58.47
|
| Rate for Payer: Cigna Commercial |
$97.05
|
| Rate for Payer: First Health Commercial |
$111.08
|
| Rate for Payer: Humana Commercial |
$99.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.90
|
| Rate for Payer: Ohio Health Group HMO |
$87.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.25
|
| Rate for Payer: PHCS Commercial |
$112.25
|
| Rate for Payer: United Healthcare All Payer |
$102.90
|
|
|
GENTAMICIN 80 MG [140MG SYR]
|
Facility
|
OP
|
$116.93
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$112.25 |
| Rate for Payer: Aetna Commercial |
$90.04
|
| Rate for Payer: Anthem Medicaid |
$40.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.21
|
| Rate for Payer: Cash Price |
$58.47
|
| Rate for Payer: Cigna Commercial |
$97.05
|
| Rate for Payer: First Health Commercial |
$111.08
|
| Rate for Payer: Humana Commercial |
$99.39
|
| Rate for Payer: Humana KY Medicaid |
$40.21
|
| Rate for Payer: Kentucky WC Medicaid |
$40.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.90
|
| Rate for Payer: Ohio Health Group HMO |
$87.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.25
|
| Rate for Payer: PHCS Commercial |
$112.25
|
| Rate for Payer: United Healthcare All Payer |
$102.90
|
|
|
Gentamicin 80mg(500mg IVPB)ANE
|
Facility
|
IP
|
$181.44
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$174.18 |
| Rate for Payer: Aetna Commercial |
$139.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.52
|
| Rate for Payer: Cash Price |
$90.72
|
| Rate for Payer: Cigna Commercial |
$150.60
|
| Rate for Payer: First Health Commercial |
$172.37
|
| Rate for Payer: Humana Commercial |
$154.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.67
|
| Rate for Payer: Ohio Health Group HMO |
$136.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.25
|
| Rate for Payer: PHCS Commercial |
$174.18
|
| Rate for Payer: United Healthcare All Payer |
$159.67
|
|
|
Gentamicin 80mg(500mg IVPB)ANE
|
Facility
|
OP
|
$181.44
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$174.18 |
| Rate for Payer: Anthem Medicaid |
$62.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.52
|
| Rate for Payer: Cash Price |
$90.72
|
| Rate for Payer: Cigna Commercial |
$150.60
|
| Rate for Payer: First Health Commercial |
$172.37
|
| Rate for Payer: Humana Commercial |
$154.22
|
| Rate for Payer: Humana KY Medicaid |
$62.40
|
| Rate for Payer: Kentucky WC Medicaid |
$63.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.67
|
| Rate for Payer: Ohio Health Group HMO |
$136.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.25
|
| Rate for Payer: PHCS Commercial |
$174.18
|
| Rate for Payer: United Healthcare All Payer |
$159.67
|
| Rate for Payer: Aetna Commercial |
$139.71
|
|
|
Gentamicin 80mg IVPB ANE
|
Facility
|
IP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$76.87 |
| Rate for Payer: Aetna Commercial |
$61.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.45
|
| Rate for Payer: Cash Price |
$40.03
|
| Rate for Payer: Cigna Commercial |
$66.46
|
| Rate for Payer: First Health Commercial |
$76.07
|
| Rate for Payer: Humana Commercial |
$68.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.46
|
| Rate for Payer: Ohio Health Group HMO |
$60.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.82
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
Gentamicin 80mg IVPB ANE
|
Facility
|
OP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$76.87 |
| Rate for Payer: Aetna Commercial |
$61.65
|
| Rate for Payer: Anthem Medicaid |
$27.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.45
|
| Rate for Payer: Cash Price |
$40.03
|
| Rate for Payer: Cigna Commercial |
$66.46
|
| Rate for Payer: First Health Commercial |
$76.07
|
| Rate for Payer: Humana Commercial |
$68.06
|
| Rate for Payer: Humana KY Medicaid |
$27.54
|
| Rate for Payer: Kentucky WC Medicaid |
$27.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.46
|
| Rate for Payer: Ohio Health Group HMO |
$60.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.82
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
63600033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
636T0033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
IP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$76.87 |
| Rate for Payer: Aetna Commercial |
$61.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.45
|
| Rate for Payer: Cash Price |
$40.03
|
| Rate for Payer: Cigna Commercial |
$66.46
|
| Rate for Payer: First Health Commercial |
$76.07
|
| Rate for Payer: Humana Commercial |
$68.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.46
|
| Rate for Payer: Ohio Health Group HMO |
$60.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.82
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
63600033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
636T0033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
OP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$76.87 |
| Rate for Payer: Aetna Commercial |
$61.65
|
| Rate for Payer: Anthem Medicaid |
$27.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.45
|
| Rate for Payer: Cash Price |
$40.03
|
| Rate for Payer: Cigna Commercial |
$66.46
|
| Rate for Payer: First Health Commercial |
$76.07
|
| Rate for Payer: Humana Commercial |
$68.06
|
| Rate for Payer: Humana KY Medicaid |
$27.54
|
| Rate for Payer: Kentucky WC Medicaid |
$27.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.46
|
| Rate for Payer: Ohio Health Group HMO |
$60.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.82
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
63600033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2.77
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
|
|
GENTAMYCIN 40MG/ML 20ML VIAL
|
Facility
|
IP
|
$189.31
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.61 |
| Max. Negotiated Rate |
$181.74 |
| Rate for Payer: Aetna Commercial |
$145.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.66
|
| Rate for Payer: Cash Price |
$94.66
|
| Rate for Payer: Cigna Commercial |
$157.13
|
| Rate for Payer: First Health Commercial |
$179.84
|
| Rate for Payer: Humana Commercial |
$160.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.59
|
| Rate for Payer: Ohio Health Group HMO |
$141.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.69
|
| Rate for Payer: PHCS Commercial |
$181.74
|
| Rate for Payer: United Healthcare All Payer |
$166.59
|
|
|
GENTAMYCIN 40MG/ML 20ML VIAL
|
Facility
|
OP
|
$189.31
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.61 |
| Max. Negotiated Rate |
$181.74 |
| Rate for Payer: Aetna Commercial |
$145.77
|
| Rate for Payer: Anthem Medicaid |
$65.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.66
|
| Rate for Payer: Cash Price |
$94.66
|
| Rate for Payer: Cigna Commercial |
$157.13
|
| Rate for Payer: First Health Commercial |
$179.84
|
| Rate for Payer: Humana Commercial |
$160.91
|
| Rate for Payer: Humana KY Medicaid |
$65.10
|
| Rate for Payer: Kentucky WC Medicaid |
$65.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.59
|
| Rate for Payer: Ohio Health Group HMO |
$141.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.69
|
| Rate for Payer: PHCS Commercial |
$181.74
|
| Rate for Payer: United Healthcare All Payer |
$166.59
|
|
|
GENTAMYCIN (PEAK)
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
30000030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$103.68 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Anthem Medicaid |
$16.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.38
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$89.64
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: Humana Commercial |
$91.80
|
| Rate for Payer: Humana KY Medicaid |
$16.38
|
| Rate for Payer: Humana Medicare Advantage |
$16.38
|
| Rate for Payer: Kentucky WC Medicaid |
$16.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.04
|
| Rate for Payer: Ohio Health Group HMO |
$81.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.48
|
| Rate for Payer: PHCS Commercial |
$103.68
|
| Rate for Payer: United Healthcare All Payer |
$95.04
|
|
|
GENTAMYCIN (PEAK)
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
30000030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$103.68 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$89.64
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: Humana Commercial |
$91.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.04
|
| Rate for Payer: Ohio Health Group HMO |
$81.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.48
|
| Rate for Payer: PHCS Commercial |
$103.68
|
| Rate for Payer: United Healthcare All Payer |
$95.04
|
|
|
GENTEAL TEARS EYE DROPS
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 65042636
|
| Hospital Charge Code |
25003080
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
|
GENTEAL TEARS EYE DROPS
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 65042636
|
| Hospital Charge Code |
25003080
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
