|
GENTIAN VIOLET
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 395100392
|
| Hospital Charge Code |
25003081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna Commercial |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.09
|
| Rate for Payer: First Health Commercial |
$0.10
|
| Rate for Payer: Humana Commercial |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.10
|
| Rate for Payer: Ohio Health Group HMO |
$0.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
GENTIAN VIOLET
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 395100392
|
| Hospital Charge Code |
25003081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna Commercial |
$0.08
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.09
|
| Rate for Payer: First Health Commercial |
$0.10
|
| Rate for Payer: Humana Commercial |
$0.09
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.10
|
| Rate for Payer: Ohio Health Group HMO |
$0.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
GENTIAN VIOLET 2% SOLUTION
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 395100592
|
| Hospital Charge Code |
25000716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.16
|
| Rate for Payer: Anthem Medicaid |
$0.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.17
|
| Rate for Payer: First Health Commercial |
$0.20
|
| Rate for Payer: Humana Commercial |
$0.18
|
| Rate for Payer: Humana KY Medicaid |
$0.07
|
| Rate for Payer: Kentucky WC Medicaid |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.18
|
| Rate for Payer: Ohio Health Group HMO |
$0.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
GENTIAN VIOLET 2% SOLUTION
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 395100592
|
| Hospital Charge Code |
25000716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.17
|
| Rate for Payer: First Health Commercial |
$0.20
|
| Rate for Payer: Humana Commercial |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.18
|
| Rate for Payer: Ohio Health Group HMO |
$0.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
GEN TIB BASEPLATE SZ3 LT HA
|
Facility
|
OP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem Medicaid |
$3,194.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Humana KY Medicaid |
$3,194.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,226.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,258.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ3 LT HA
|
Facility
|
IP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ5 LT HA
|
Facility
|
IP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ5 LT HA
|
Facility
|
OP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem Medicaid |
$3,194.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Humana KY Medicaid |
$3,194.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,226.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,258.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ6 LT HA
|
Facility
|
IP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ6 LT HA
|
Facility
|
OP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem Medicaid |
$3,194.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Humana KY Medicaid |
$3,194.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,226.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,258.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ7 LT HA
|
Facility
|
OP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem Medicaid |
$3,194.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Humana KY Medicaid |
$3,194.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,226.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,258.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ7 LT HA
|
Facility
|
IP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ8 LT HA
|
Facility
|
OP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem Medicaid |
$3,194.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Humana KY Medicaid |
$3,194.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,226.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,258.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GEN TIB BASEPLATE SZ8 LT HA
|
Facility
|
IP
|
$9,288.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.54 |
| Max. Negotiated Rate |
$8,917.24 |
| Rate for Payer: Aetna Commercial |
$7,152.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,245.26
|
| Rate for Payer: Cash Price |
$4,644.39
|
| Rate for Payer: Cigna Commercial |
$7,709.70
|
| Rate for Payer: First Health Commercial |
$8,824.35
|
| Rate for Payer: Humana Commercial |
$7,895.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,616.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,855.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,786.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,174.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,966.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,857.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,879.52
|
| Rate for Payer: PHCS Commercial |
$8,917.24
|
| Rate for Payer: United Healthcare All Payer |
$8,174.14
|
|
|
GENTLE CLEANSER 200 ML GBL
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
22200142
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
GEODON 10MG [20 MG VIAL]
|
Facility
|
IP
|
$136.43
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
25002451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.74 |
| Max. Negotiated Rate |
$130.97 |
| Rate for Payer: Aetna Commercial |
$105.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.42
|
| Rate for Payer: Cash Price |
$68.22
|
| Rate for Payer: Cigna Commercial |
$113.24
|
| Rate for Payer: First Health Commercial |
$129.61
|
| Rate for Payer: Humana Commercial |
$115.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$120.06
|
| Rate for Payer: Ohio Health Group HMO |
$102.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.29
|
| Rate for Payer: PHCS Commercial |
$130.97
|
| Rate for Payer: United Healthcare All Payer |
$120.06
|
|
|
GEODON 10MG [20 MG VIAL]
|
Facility
|
OP
|
$136.43
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
25002451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.74 |
| Max. Negotiated Rate |
$130.97 |
| Rate for Payer: Aetna Commercial |
$105.05
|
| Rate for Payer: Anthem Medicaid |
$46.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.42
|
| Rate for Payer: Cash Price |
$68.22
|
| Rate for Payer: Cigna Commercial |
$113.24
|
| Rate for Payer: First Health Commercial |
$129.61
|
| Rate for Payer: Humana Commercial |
$115.97
|
| Rate for Payer: Humana KY Medicaid |
$46.92
|
| Rate for Payer: Kentucky WC Medicaid |
$47.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$120.06
|
| Rate for Payer: Ohio Health Group HMO |
$102.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.29
|
| Rate for Payer: PHCS Commercial |
$130.97
|
| Rate for Payer: United Healthcare All Payer |
$120.06
|
|
|
GEODON 40 MG CAPSULE
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 68001045106
|
| Hospital Charge Code |
25000717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.99
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.24
|
| Rate for Payer: First Health Commercial |
$4.85
|
| Rate for Payer: Humana Commercial |
$4.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.50
|
| Rate for Payer: Ohio Health Group HMO |
$3.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Payer |
$4.50
|
|
|
GEODON 40 MG CAPSULE
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 68001045106
|
| Hospital Charge Code |
25000717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem Medicaid |
$1.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.99
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.24
|
| Rate for Payer: First Health Commercial |
$4.85
|
| Rate for Payer: Humana Commercial |
$4.34
|
| Rate for Payer: Humana KY Medicaid |
$1.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.50
|
| Rate for Payer: Ohio Health Group HMO |
$3.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Payer |
$4.50
|
|
|
GEODON(ZIPRASIDONE) 20MG TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 65862070260
|
| Hospital Charge Code |
25000718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
GEODON(ZIPRASIDONE) 20MG TAB
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 65862070260
|
| Hospital Charge Code |
25000718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
|
|
GEODON(ZIPRASIDONE)60MG TAB
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 68180033307
|
| Hospital Charge Code |
25000720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
GEODON(ZIPRASIDONE)60MG TAB
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 68180033307
|
| Hospital Charge Code |
25000720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Humana KY Medicaid |
$3.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
GEODON(ZIPRASIDONE) 80MG TAB
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 68180033407
|
| Hospital Charge Code |
25000719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
GEODON(ZIPRASIDONE) 80MG TAB
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 68180033407
|
| Hospital Charge Code |
25000719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Humana KY Medicaid |
$3.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
