|
GEN TIB BASEPLATE SZ7 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 SZ7 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 SZ8 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 SZ8 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
|
|
|
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 |
$31.50 |
| 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
|
|
|
GENTLE CLEANSER 200 ML GBL
|
Facility
|
OP
|
$45.00
|
|
| Hospital Charge Code |
22200142
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
GENTLE CLEANSER 200 ML GBL
|
Facility
|
IP
|
$45.00
|
|
| Hospital Charge Code |
22200142
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
GEODON 10MG [20 MG VIAL]
|
Facility
|
OP
|
$136.43
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
25002451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.93 |
| 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 |
$109.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.14
|
| Rate for Payer: PHCS Commercial |
$130.97
|
| Rate for Payer: United Healthcare All Payer |
$120.06
|
|
|
GEODON 10MG [20 MG VIAL]
|
Facility
|
IP
|
$136.43
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
25002451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.93 |
| 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 |
$109.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.14
|
| Rate for Payer: PHCS Commercial |
$130.97
|
| Rate for Payer: United Healthcare All Payer |
$120.06
|
|
|
GEODON 40 MG CAPSULE
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 68001045106
|
| Hospital Charge Code |
25000717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| 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 |
$4.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.53
|
| Rate for Payer: PHCS Commercial |
$4.91
|
| Rate for Payer: United Healthcare All Payer |
$4.50
|
|
|
GEODON 40 MG CAPSULE
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 68001045106
|
| Hospital Charge Code |
25000717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| 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 |
$4.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.53
|
| 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 |
$1.39 |
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| 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 |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| 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
|
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
GEODON(ZIPRASIDONE)60MG TAB
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 68180033307
|
| Hospital Charge Code |
25000720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
GEODON(ZIPRASIDONE)60MG TAB
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 68180033307
|
| Hospital Charge Code |
25000720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| 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 |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| 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 |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
GERMAN COCKROACH IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000689
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
GERMAN COCKROACH IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000689
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
G-ESOPH REFLX TST W/ELECTROD
|
Facility
|
IP
|
$2,330.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
75000003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$699.00 |
| Max. Negotiated Rate |
$2,236.80 |
| Rate for Payer: Aetna Commercial |
$1,794.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,817.40
|
| Rate for Payer: Cash Price |
$1,165.00
|
| Rate for Payer: Cigna Commercial |
$1,933.90
|
| Rate for Payer: First Health Commercial |
$2,213.50
|
| Rate for Payer: Humana Commercial |
$1,980.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,910.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,719.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$699.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,050.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,747.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,864.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,027.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.70
|
| Rate for Payer: PHCS Commercial |
$2,236.80
|
| Rate for Payer: United Healthcare All Payer |
$2,050.40
|
|
|
G-ESOPH REFLX TST W/ELECTROD
|
Facility
|
OP
|
$2,330.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
75000003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$490.26 |
| Max. Negotiated Rate |
$2,236.80 |
| Rate for Payer: Aetna Commercial |
$1,794.10
|
| Rate for Payer: Anthem Medicaid |
$801.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,817.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$1,165.00
|
| Rate for Payer: Cash Price |
$1,165.00
|
| Rate for Payer: Cigna Commercial |
$1,933.90
|
| Rate for Payer: First Health Commercial |
$2,213.50
|
| Rate for Payer: Humana Commercial |
$1,980.50
|
| Rate for Payer: Humana KY Medicaid |
$801.29
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$809.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,910.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,719.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$817.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,050.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,747.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,864.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,027.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.70
|
| Rate for Payer: PHCS Commercial |
$2,236.80
|
| Rate for Payer: United Healthcare All Payer |
$2,050.40
|
|
|
G-ESOPH REFLX TST W/ELECTROD
|
Professional
|
Both
|
$2,330.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
75000003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$108.10 |
| Max. Negotiated Rate |
$1,398.00 |
| Rate for Payer: Aetna Commercial |
$684.78
|
| Rate for Payer: Ambetter Exchange |
$391.49
|
| Rate for Payer: Anthem Medicaid |
$325.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.79
|
| Rate for Payer: Cash Price |
$1,165.00
|
| Rate for Payer: Cash Price |
$1,165.00
|
| Rate for Payer: Cigna Commercial |
$602.95
|
| Rate for Payer: Healthspan PPO |
$560.38
|
| Rate for Payer: Humana Medicaid |
$325.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$108.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$391.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$332.38
|
| Rate for Payer: Molina Healthcare Passport |
$325.86
|
| Rate for Payer: Multiplan PHCS |
$1,398.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$508.94
|
| Rate for Payer: UHCCP Medicaid |
$815.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$329.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.49
|
|
|
G-ESOPH REFLX TST W/ELECTRO(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
750P0003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$684.78 |
| Rate for Payer: Aetna Commercial |
$684.78
|
| Rate for Payer: Ambetter Exchange |
$391.49
|
| Rate for Payer: Anthem Medicaid |
$325.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.79
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$602.95
|
| Rate for Payer: Healthspan PPO |
$560.38
|
| Rate for Payer: Humana Medicaid |
$325.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$108.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$391.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$332.38
|
| Rate for Payer: Molina Healthcare Passport |
$325.86
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$508.94
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$329.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.49
|
|
|
G-ESOPH REFLX TST W/ELECTRO(T
|
Facility
|
IP
|
$2,130.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
750T0003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$639.00 |
| Max. Negotiated Rate |
$2,044.80 |
| Rate for Payer: Aetna Commercial |
$1,640.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,661.40
|
| Rate for Payer: Cash Price |
$1,065.00
|
| Rate for Payer: Cigna Commercial |
$1,767.90
|
| Rate for Payer: First Health Commercial |
$2,023.50
|
| Rate for Payer: Humana Commercial |
$1,810.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,746.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,571.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$639.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,874.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,597.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,853.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,469.70
|
| Rate for Payer: PHCS Commercial |
$2,044.80
|
| Rate for Payer: United Healthcare All Payer |
$1,874.40
|
|
|
G-ESOPH REFLX TST W/ELECTRO(T
|
Facility
|
OP
|
$2,130.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
750T0003
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$490.26 |
| Max. Negotiated Rate |
$2,044.80 |
| Rate for Payer: Aetna Commercial |
$1,640.10
|
| Rate for Payer: Anthem Medicaid |
$732.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,661.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$1,065.00
|
| Rate for Payer: Cash Price |
$1,065.00
|
| Rate for Payer: Cigna Commercial |
$1,767.90
|
| Rate for Payer: First Health Commercial |
$2,023.50
|
| Rate for Payer: Humana Commercial |
$1,810.50
|
| Rate for Payer: Humana KY Medicaid |
$732.51
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$739.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,746.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,571.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$747.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,874.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,597.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,853.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,469.70
|
| Rate for Payer: PHCS Commercial |
$2,044.80
|
| Rate for Payer: United Healthcare All Payer |
$1,874.40
|
|
