|
Gentamicin 80mg IVPB ANE
|
Facility
|
IP
|
$114.62
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$110.04 |
| Rate for Payer: Aetna Commercial |
$88.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.40
|
| Rate for Payer: Cash Price |
$57.31
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: First Health Commercial |
$108.89
|
| Rate for Payer: Humana Commercial |
$97.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.87
|
| Rate for Payer: Ohio Health Group HMO |
$85.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.09
|
| Rate for Payer: PHCS Commercial |
$110.04
|
| Rate for Payer: United Healthcare All Payer |
$100.87
|
|
|
Gentamicin 80mg IVPB ANE
|
Facility
|
OP
|
$114.62
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25004147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$110.04 |
| Rate for Payer: Aetna Commercial |
$88.26
|
| Rate for Payer: Anthem Medicaid |
$39.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.40
|
| Rate for Payer: Cash Price |
$57.31
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: First Health Commercial |
$108.89
|
| Rate for Payer: Humana Commercial |
$97.43
|
| Rate for Payer: Humana KY Medicaid |
$39.42
|
| Rate for Payer: Kentucky WC Medicaid |
$39.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.87
|
| Rate for Payer: Ohio Health Group HMO |
$85.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.09
|
| Rate for Payer: PHCS Commercial |
$110.04
|
| Rate for Payer: United Healthcare All Payer |
$100.87
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
OP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
636T0033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| 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 |
$64.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.25
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
OP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
63600033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| 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 |
$64.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.25
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Professional
|
Both
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
63600033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$48.04 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Ambetter Exchange |
$2.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$2.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.14
|
| Rate for Payer: Cash Price |
$40.03
|
| Rate for Payer: Cash Price |
$40.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.62
|
| Rate for Payer: Multiplan PHCS |
$48.04
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3.41
|
| Rate for Payer: UHCCP Medicaid |
$28.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$2.62
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
IP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
636T0033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| 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 |
$64.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.25
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
OP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| 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 |
$64.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.25
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
IP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
63600033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| 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 |
$64.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.25
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMICIN 80MG SDV
|
Facility
|
IP
|
$80.07
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| 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 |
$64.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.25
|
| Rate for Payer: PHCS Commercial |
$76.87
|
| Rate for Payer: United Healthcare All Payer |
$70.46
|
|
|
GENTAMYCIN 40MG/ML 20ML VIAL
|
Facility
|
OP
|
$189.31
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.79 |
| 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 |
$151.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.62
|
| Rate for Payer: PHCS Commercial |
$181.74
|
| Rate for Payer: United Healthcare All Payer |
$166.59
|
|
|
GENTAMYCIN 40MG/ML 20ML VIAL
|
Facility
|
IP
|
$189.31
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
25002117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.79 |
| 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 |
$151.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.62
|
| Rate for Payer: PHCS Commercial |
$181.74
|
| Rate for Payer: United Healthcare All Payer |
$166.59
|
|
|
GENTAMYCIN (PEAK)
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
30000030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$109.44 |
| Rate for Payer: Aetna Commercial |
$87.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.54
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: First Health Commercial |
$108.30
|
| Rate for Payer: Humana Commercial |
$96.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.32
|
| Rate for Payer: Ohio Health Group HMO |
$85.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.66
|
| Rate for Payer: PHCS Commercial |
$109.44
|
| Rate for Payer: United Healthcare All Payer |
$100.32
|
|
|
GENTAMYCIN (PEAK)
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
30000030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$109.44 |
| Rate for Payer: Aetna Commercial |
$87.78
|
| Rate for Payer: Anthem Medicaid |
$16.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.38
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: First Health Commercial |
$108.30
|
| Rate for Payer: Humana Commercial |
$96.90
|
| 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 |
$93.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.32
|
| Rate for Payer: Ohio Health Group HMO |
$85.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.66
|
| Rate for Payer: PHCS Commercial |
$109.44
|
| Rate for Payer: United Healthcare All Payer |
$100.32
|
|
|
GENTEAL TEARS EYE DROPS
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 65042636
|
| Hospital Charge Code |
25003080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| 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
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 65042636
|
| Hospital Charge Code |
25003080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| 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
|
|
|
GENTIAN VIOLET
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 395100392
|
| Hospital Charge Code |
25003081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| 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 |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
GENTIAN VIOLET
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 395100392
|
| Hospital Charge Code |
25003081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| 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 |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
GENTIAN VIOLET 2% SOLUTION
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 395100592
|
| Hospital Charge Code |
25000716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| 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 |
$0.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.14
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
GENTIAN VIOLET 2% SOLUTION
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 395100592
|
| Hospital Charge Code |
25000716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| 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 |
$0.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.14
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
GEN TIB BASEPLATE SZ3 LT HA
|
Facility
|
IP
|
$9,488.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.64 |
| Max. Negotiated Rate |
$9,109.24 |
| Rate for Payer: Aetna Commercial |
$7,306.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,401.26
|
| Rate for Payer: Cash Price |
$4,744.39
|
| Rate for Payer: Cigna Commercial |
$7,875.70
|
| Rate for Payer: First Health Commercial |
$9,014.35
|
| Rate for Payer: Humana Commercial |
$8,065.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,780.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,350.14
|
| Rate for Payer: Ohio Health Group HMO |
$7,116.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,591.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,255.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,547.27
|
| Rate for Payer: PHCS Commercial |
$9,109.24
|
| Rate for Payer: United Healthcare All Payer |
$8,350.14
|
|
|
GEN TIB BASEPLATE SZ3 LT HA
|
Facility
|
OP
|
$9,488.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.64 |
| Max. Negotiated Rate |
$9,109.24 |
| Rate for Payer: Aetna Commercial |
$7,306.37
|
| Rate for Payer: Anthem Medicaid |
$3,263.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,401.26
|
| Rate for Payer: Cash Price |
$4,744.39
|
| Rate for Payer: Cigna Commercial |
$7,875.70
|
| Rate for Payer: First Health Commercial |
$9,014.35
|
| Rate for Payer: Humana Commercial |
$8,065.47
|
| Rate for Payer: Humana KY Medicaid |
$3,263.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,296.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,780.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,328.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,350.14
|
| Rate for Payer: Ohio Health Group HMO |
$7,116.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,591.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,255.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,547.27
|
| Rate for Payer: PHCS Commercial |
$9,109.24
|
| Rate for Payer: United Healthcare All Payer |
$8,350.14
|
|
|
GEN TIB BASEPLATE SZ5 LT HA
|
Facility
|
OP
|
$9,488.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.64 |
| Max. Negotiated Rate |
$9,109.24 |
| Rate for Payer: Aetna Commercial |
$7,306.37
|
| Rate for Payer: Anthem Medicaid |
$3,263.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,401.26
|
| Rate for Payer: Cash Price |
$4,744.39
|
| Rate for Payer: Cigna Commercial |
$7,875.70
|
| Rate for Payer: First Health Commercial |
$9,014.35
|
| Rate for Payer: Humana Commercial |
$8,065.47
|
| Rate for Payer: Humana KY Medicaid |
$3,263.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,296.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,780.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,328.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,350.14
|
| Rate for Payer: Ohio Health Group HMO |
$7,116.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,591.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,255.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,547.27
|
| Rate for Payer: PHCS Commercial |
$9,109.24
|
| Rate for Payer: United Healthcare All Payer |
$8,350.14
|
|
|
GEN TIB BASEPLATE SZ5 LT HA
|
Facility
|
IP
|
$9,488.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.64 |
| Max. Negotiated Rate |
$9,109.24 |
| Rate for Payer: Aetna Commercial |
$7,306.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,401.26
|
| Rate for Payer: Cash Price |
$4,744.39
|
| Rate for Payer: Cigna Commercial |
$7,875.70
|
| Rate for Payer: First Health Commercial |
$9,014.35
|
| Rate for Payer: Humana Commercial |
$8,065.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,780.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,350.14
|
| Rate for Payer: Ohio Health Group HMO |
$7,116.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,591.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,255.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,547.27
|
| Rate for Payer: PHCS Commercial |
$9,109.24
|
| Rate for Payer: United Healthcare All Payer |
$8,350.14
|
|
|
GEN TIB BASEPLATE SZ6 LT HA
|
Facility
|
OP
|
$9,488.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.64 |
| Max. Negotiated Rate |
$9,109.24 |
| Rate for Payer: Aetna Commercial |
$7,306.37
|
| Rate for Payer: Anthem Medicaid |
$3,263.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,401.26
|
| Rate for Payer: Cash Price |
$4,744.39
|
| Rate for Payer: Cigna Commercial |
$7,875.70
|
| Rate for Payer: First Health Commercial |
$9,014.35
|
| Rate for Payer: Humana Commercial |
$8,065.47
|
| Rate for Payer: Humana KY Medicaid |
$3,263.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,296.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,780.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,328.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,350.14
|
| Rate for Payer: Ohio Health Group HMO |
$7,116.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,591.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,255.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,547.27
|
| Rate for Payer: PHCS Commercial |
$9,109.24
|
| Rate for Payer: United Healthcare All Payer |
$8,350.14
|
|
|
GEN TIB BASEPLATE SZ6 LT HA
|
Facility
|
IP
|
$9,488.79
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.64 |
| Max. Negotiated Rate |
$9,109.24 |
| Rate for Payer: Aetna Commercial |
$7,306.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,401.26
|
| Rate for Payer: Cash Price |
$4,744.39
|
| Rate for Payer: Cigna Commercial |
$7,875.70
|
| Rate for Payer: First Health Commercial |
$9,014.35
|
| Rate for Payer: Humana Commercial |
$8,065.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,780.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,350.14
|
| Rate for Payer: Ohio Health Group HMO |
$7,116.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,591.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,255.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,547.27
|
| Rate for Payer: PHCS Commercial |
$9,109.24
|
| Rate for Payer: United Healthcare All Payer |
$8,350.14
|
|
