|
GENRTR ALTRUA 40 DCRR S402/03
|
Facility
|
IP
|
$21,875.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
GENRTR ALTRUA 60 DCRR S602/03
|
Facility
|
IP
|
$21,875.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
GENRTR ALTRUA 60 DCRR S602/03
|
Facility
|
OP
|
$21,875.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem Medicaid |
$7,522.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Humana KY Medicaid |
$7,522.81
|
| Rate for Payer: Kentucky WC Medicaid |
$7,599.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,673.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
GENRTR DCRR CYLOS DR-T 349806
|
Facility
|
IP
|
$27,500.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$8,250.00 |
| Max. Negotiated Rate |
$26,400.00 |
| Rate for Payer: Aetna Commercial |
$21,175.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,450.00
|
| Rate for Payer: Cash Price |
$13,750.00
|
| Rate for Payer: Cigna Commercial |
$22,825.00
|
| Rate for Payer: First Health Commercial |
$26,125.00
|
| Rate for Payer: Humana Commercial |
$23,375.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,550.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,295.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,250.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$20,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,925.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,975.00
|
| Rate for Payer: PHCS Commercial |
$26,400.00
|
| Rate for Payer: United Healthcare All Payer |
$24,200.00
|
|
|
GENRTR DCRR CYLOS DR-T 349806
|
Facility
|
OP
|
$27,500.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$8,250.00 |
| Max. Negotiated Rate |
$26,400.00 |
| Rate for Payer: Aetna Commercial |
$21,175.00
|
| Rate for Payer: Anthem Medicaid |
$9,457.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,450.00
|
| Rate for Payer: Cash Price |
$13,750.00
|
| Rate for Payer: Cigna Commercial |
$22,825.00
|
| Rate for Payer: First Health Commercial |
$26,125.00
|
| Rate for Payer: Humana Commercial |
$23,375.00
|
| Rate for Payer: Humana KY Medicaid |
$9,457.25
|
| Rate for Payer: Kentucky WC Medicaid |
$9,553.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,550.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,295.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,250.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,647.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$20,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,925.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,975.00
|
| Rate for Payer: PHCS Commercial |
$26,400.00
|
| Rate for Payer: United Healthcare All Payer |
$24,200.00
|
|
|
GENRTR EON MINI IPG 16 CHANEL
|
Facility
|
OP
|
$84,600.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,380.00 |
| Max. Negotiated Rate |
$81,216.00 |
| Rate for Payer: Aetna Commercial |
$65,142.00
|
| Rate for Payer: Anthem Medicaid |
$29,093.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,988.00
|
| Rate for Payer: Cash Price |
$42,300.00
|
| Rate for Payer: Cigna Commercial |
$70,218.00
|
| Rate for Payer: First Health Commercial |
$80,370.00
|
| Rate for Payer: Humana Commercial |
$71,910.00
|
| Rate for Payer: Humana KY Medicaid |
$29,093.94
|
| Rate for Payer: Kentucky WC Medicaid |
$29,390.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69,372.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62,434.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,380.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,677.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$74,448.00
|
| Rate for Payer: Ohio Health Group HMO |
$63,450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73,602.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,374.00
|
| Rate for Payer: PHCS Commercial |
$81,216.00
|
| Rate for Payer: United Healthcare All Payer |
$74,448.00
|
|
|
GENRTR EON MINI IPG 16 CHANEL
|
Facility
|
IP
|
$84,600.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,380.00 |
| Max. Negotiated Rate |
$81,216.00 |
| Rate for Payer: Aetna Commercial |
$65,142.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,988.00
|
| Rate for Payer: Cash Price |
$42,300.00
|
| Rate for Payer: Cigna Commercial |
$70,218.00
|
| Rate for Payer: First Health Commercial |
$80,370.00
|
| Rate for Payer: Humana Commercial |
$71,910.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69,372.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62,434.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,380.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$74,448.00
|
| Rate for Payer: Ohio Health Group HMO |
$63,450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73,602.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,374.00
|
| Rate for Payer: PHCS Commercial |
$81,216.00
|
| Rate for Payer: United Healthcare All Payer |
$74,448.00
|
|
|
GENRTR INSYNC II MARQUIS 7289
|
Facility
|
IP
|
$104,550.00
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$31,365.00 |
| Max. Negotiated Rate |
$100,368.00 |
| Rate for Payer: Aetna Commercial |
$80,503.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81,549.00
|
| Rate for Payer: Cash Price |
$52,275.00
|
| Rate for Payer: Cigna Commercial |
$86,776.50
|
| Rate for Payer: First Health Commercial |
$99,322.50
|
| Rate for Payer: Humana Commercial |
$88,867.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$77,157.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31,365.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$92,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$78,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83,640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90,958.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72,139.50
|
| Rate for Payer: PHCS Commercial |
$100,368.00
|
| Rate for Payer: United Healthcare All Payer |
$92,004.00
|
|
|
GENRTR INSYNC II MARQUIS 7289
|
Facility
|
OP
|
$104,550.00
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$31,365.00 |
| Max. Negotiated Rate |
$100,368.00 |
| Rate for Payer: Aetna Commercial |
$80,503.50
|
| Rate for Payer: Anthem Medicaid |
$35,954.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81,549.00
|
| Rate for Payer: Cash Price |
$52,275.00
|
| Rate for Payer: Cigna Commercial |
$86,776.50
|
| Rate for Payer: First Health Commercial |
$99,322.50
|
| Rate for Payer: Humana Commercial |
$88,867.50
|
| Rate for Payer: Humana KY Medicaid |
$35,954.75
|
| Rate for Payer: Kentucky WC Medicaid |
$36,320.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$77,157.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31,365.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$36,676.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$92,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$78,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83,640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90,958.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72,139.50
|
| Rate for Payer: PHCS Commercial |
$100,368.00
|
| Rate for Payer: United Healthcare All Payer |
$92,004.00
|
|
|
GENRTR ZEPHYR XL DR DCRR 5826
|
Facility
|
IP
|
$21,875.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
GENRTR ZEPHYR XL DR DCRR 5826
|
Facility
|
OP
|
$21,875.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem Medicaid |
$7,522.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Humana KY Medicaid |
$7,522.81
|
| Rate for Payer: Kentucky WC Medicaid |
$7,599.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,673.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
GENTAMICIN 20MG PF SDV
|
Facility
|
IP
|
$112.41
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.72 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna Commercial |
$86.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.68
|
| Rate for Payer: Cash Price |
$56.20
|
| Rate for Payer: Cigna Commercial |
$93.30
|
| Rate for Payer: First Health Commercial |
$106.79
|
| Rate for Payer: Humana Commercial |
$95.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.92
|
| Rate for Payer: Ohio Health Group HMO |
$84.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.56
|
| Rate for Payer: PHCS Commercial |
$107.91
|
| Rate for Payer: United Healthcare All Payer |
$98.92
|
|
|
GENTAMICIN 20MG PF SDV
|
Facility
|
OP
|
$112.41
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.72 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna Commercial |
$86.56
|
| Rate for Payer: Anthem Medicaid |
$38.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.68
|
| Rate for Payer: Cash Price |
$56.20
|
| Rate for Payer: Cigna Commercial |
$93.30
|
| Rate for Payer: First Health Commercial |
$106.79
|
| Rate for Payer: Humana Commercial |
$95.55
|
| Rate for Payer: Humana KY Medicaid |
$38.66
|
| Rate for Payer: Kentucky WC Medicaid |
$39.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.92
|
| Rate for Payer: Ohio Health Group HMO |
$84.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.56
|
| Rate for Payer: PHCS Commercial |
$107.91
|
| Rate for Payer: United Healthcare All Payer |
$98.92
|
|
|
GENTAMICIN 280MG/107ML IN D5W
|
Facility
|
IP
|
$126.32
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.90 |
| Max. Negotiated Rate |
$121.27 |
| Rate for Payer: Aetna Commercial |
$97.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.53
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Cigna Commercial |
$104.85
|
| Rate for Payer: First Health Commercial |
$120.00
|
| Rate for Payer: Humana Commercial |
$107.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.16
|
| Rate for Payer: Ohio Health Group HMO |
$94.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.16
|
| Rate for Payer: PHCS Commercial |
$121.27
|
| Rate for Payer: United Healthcare All Payer |
$111.16
|
|
|
GENTAMICIN 280MG/107ML IN D5W
|
Facility
|
OP
|
$126.32
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.90 |
| Max. Negotiated Rate |
$121.27 |
| Rate for Payer: Aetna Commercial |
$97.27
|
| Rate for Payer: Anthem Medicaid |
$43.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.53
|
| Rate for Payer: Cash Price |
$63.16
|
| Rate for Payer: Cigna Commercial |
$104.85
|
| Rate for Payer: First Health Commercial |
$120.00
|
| Rate for Payer: Humana Commercial |
$107.37
|
| Rate for Payer: Humana KY Medicaid |
$43.44
|
| Rate for Payer: Kentucky WC Medicaid |
$43.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.16
|
| Rate for Payer: Ohio Health Group HMO |
$94.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.16
|
| Rate for Payer: PHCS Commercial |
$121.27
|
| Rate for Payer: United Healthcare All Payer |
$111.16
|
|
|
GENTAMICIN 340MG/108.5ML D5W
|
Facility
|
IP
|
$129.80
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.94 |
| Max. Negotiated Rate |
$124.61 |
| Rate for Payer: Aetna Commercial |
$99.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$101.24
|
| Rate for Payer: Cash Price |
$64.90
|
| Rate for Payer: Cigna Commercial |
$107.73
|
| Rate for Payer: First Health Commercial |
$123.31
|
| Rate for Payer: Humana Commercial |
$110.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.22
|
| Rate for Payer: Ohio Health Group HMO |
$97.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.56
|
| Rate for Payer: PHCS Commercial |
$124.61
|
| Rate for Payer: United Healthcare All Payer |
$114.22
|
|
|
GENTAMICIN 340MG/108.5ML D5W
|
Facility
|
OP
|
$129.80
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.94 |
| Max. Negotiated Rate |
$124.61 |
| Rate for Payer: Aetna Commercial |
$99.95
|
| Rate for Payer: Anthem Medicaid |
$44.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$101.24
|
| Rate for Payer: Cash Price |
$64.90
|
| Rate for Payer: Cigna Commercial |
$107.73
|
| Rate for Payer: First Health Commercial |
$123.31
|
| Rate for Payer: Humana Commercial |
$110.33
|
| Rate for Payer: Humana KY Medicaid |
$44.64
|
| Rate for Payer: Kentucky WC Medicaid |
$45.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.22
|
| Rate for Payer: Ohio Health Group HMO |
$97.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.56
|
| Rate for Payer: PHCS Commercial |
$124.61
|
| Rate for Payer: United Healthcare All Payer |
$114.22
|
|
|
GENTAMICIN 400MG/110ML IN D5/W
|
Facility
|
OP
|
$182.28
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.68 |
| Max. Negotiated Rate |
$174.99 |
| Rate for Payer: Aetna Commercial |
$140.36
|
| Rate for Payer: Anthem Medicaid |
$62.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.18
|
| Rate for Payer: Cash Price |
$91.14
|
| Rate for Payer: Cigna Commercial |
$151.29
|
| Rate for Payer: First Health Commercial |
$173.17
|
| Rate for Payer: Humana Commercial |
$154.94
|
| Rate for Payer: Humana KY Medicaid |
$62.69
|
| Rate for Payer: Kentucky WC Medicaid |
$63.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.41
|
| Rate for Payer: Ohio Health Group HMO |
$136.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.77
|
| Rate for Payer: PHCS Commercial |
$174.99
|
| Rate for Payer: United Healthcare All Payer |
$160.41
|
|
|
GENTAMICIN 400MG/110ML IN D5/W
|
Facility
|
IP
|
$182.28
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.68 |
| Max. Negotiated Rate |
$174.99 |
| Rate for Payer: Aetna Commercial |
$140.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.18
|
| Rate for Payer: Cash Price |
$91.14
|
| Rate for Payer: Cigna Commercial |
$151.29
|
| Rate for Payer: First Health Commercial |
$173.17
|
| Rate for Payer: Humana Commercial |
$154.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.41
|
| Rate for Payer: Ohio Health Group HMO |
$136.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.77
|
| Rate for Payer: PHCS Commercial |
$174.99
|
| Rate for Payer: United Healthcare All Payer |
$160.41
|
|
|
Gentamicin 80mg(100mg IVPB)ANE
|
Facility
|
IP
|
$115.78
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.73 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Aetna Commercial |
$89.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.31
|
| Rate for Payer: Cash Price |
$57.89
|
| Rate for Payer: Cigna Commercial |
$96.10
|
| Rate for Payer: First Health Commercial |
$109.99
|
| Rate for Payer: Humana Commercial |
$98.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.89
|
| Rate for Payer: Ohio Health Group HMO |
$86.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.89
|
| Rate for Payer: PHCS Commercial |
$111.15
|
| Rate for Payer: United Healthcare All Payer |
$101.89
|
|
|
Gentamicin 80mg(100mg IVPB)ANE
|
Facility
|
OP
|
$115.78
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.73 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Aetna Commercial |
$89.15
|
| Rate for Payer: Anthem Medicaid |
$39.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.31
|
| Rate for Payer: Cash Price |
$57.89
|
| Rate for Payer: Cigna Commercial |
$96.10
|
| Rate for Payer: First Health Commercial |
$109.99
|
| Rate for Payer: Humana Commercial |
$98.41
|
| Rate for Payer: Humana KY Medicaid |
$39.82
|
| Rate for Payer: Kentucky WC Medicaid |
$40.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.89
|
| Rate for Payer: Ohio Health Group HMO |
$86.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.89
|
| Rate for Payer: PHCS Commercial |
$111.15
|
| Rate for Payer: United Healthcare All Payer |
$101.89
|
|
|
GENTAMICIN 80 MG [140MG SYR]
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem Medicaid |
$40.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Humana KY Medicaid |
$40.24
|
| Rate for Payer: Kentucky WC Medicaid |
$40.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
GENTAMICIN 80 MG [140MG SYR]
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
Gentamicin 80mg(500mg IVPB)ANE
|
Facility
|
IP
|
$188.08
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.42 |
| Max. Negotiated Rate |
$180.56 |
| Rate for Payer: Aetna Commercial |
$144.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.70
|
| Rate for Payer: Cash Price |
$94.04
|
| Rate for Payer: Cigna Commercial |
$156.11
|
| Rate for Payer: First Health Commercial |
$178.68
|
| Rate for Payer: Humana Commercial |
$159.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$165.51
|
| Rate for Payer: Ohio Health Group HMO |
$141.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.78
|
| Rate for Payer: PHCS Commercial |
$180.56
|
| Rate for Payer: United Healthcare All Payer |
$165.51
|
|
|
Gentamicin 80mg(500mg IVPB)ANE
|
Facility
|
OP
|
$188.08
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.42 |
| Max. Negotiated Rate |
$180.56 |
| Rate for Payer: Aetna Commercial |
$144.82
|
| Rate for Payer: Anthem Medicaid |
$64.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.70
|
| Rate for Payer: Cash Price |
$94.04
|
| Rate for Payer: Cigna Commercial |
$156.11
|
| Rate for Payer: First Health Commercial |
$178.68
|
| Rate for Payer: Humana Commercial |
$159.87
|
| Rate for Payer: Humana KY Medicaid |
$64.68
|
| Rate for Payer: Kentucky WC Medicaid |
$65.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$165.51
|
| Rate for Payer: Ohio Health Group HMO |
$141.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.78
|
| Rate for Payer: PHCS Commercial |
$180.56
|
| Rate for Payer: United Healthcare All Payer |
$165.51
|
|
