|
GUIDWIR MAGIC TORQUE .035*180
|
Facility
|
OP
|
$1,099.76
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.97 |
| Max. Negotiated Rate |
$1,055.77 |
| Rate for Payer: Aetna Commercial |
$846.82
|
| Rate for Payer: Anthem Medicaid |
$378.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$857.81
|
| Rate for Payer: Cash Price |
$549.88
|
| Rate for Payer: Cigna Commercial |
$912.80
|
| Rate for Payer: First Health Commercial |
$1,044.77
|
| Rate for Payer: Humana Commercial |
$934.80
|
| Rate for Payer: Humana KY Medicaid |
$378.21
|
| Rate for Payer: Kentucky WC Medicaid |
$382.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$901.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$329.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$967.79
|
| Rate for Payer: Ohio Health Group HMO |
$824.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$219.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.93
|
| Rate for Payer: PHCS Commercial |
$1,055.77
|
| Rate for Payer: United Healthcare All Payer |
$967.79
|
|
|
GUIDWIR NTHD SPADE PT 2.0*230M
|
Facility
|
IP
|
$776.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.88 |
| Max. Negotiated Rate |
$744.96 |
| Rate for Payer: Aetna Commercial |
$597.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$605.28
|
| Rate for Payer: Cash Price |
$388.00
|
| Rate for Payer: Cigna Commercial |
$644.08
|
| Rate for Payer: First Health Commercial |
$737.20
|
| Rate for Payer: Humana Commercial |
$659.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$636.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.88
|
| Rate for Payer: Ohio Health Group HMO |
$582.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.56
|
| Rate for Payer: PHCS Commercial |
$744.96
|
| Rate for Payer: United Healthcare All Payer |
$682.88
|
|
|
GUIDWIR NTHD SPADE PT 2.0*230M
|
Facility
|
OP
|
$776.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.88 |
| Max. Negotiated Rate |
$744.96 |
| Rate for Payer: Aetna Commercial |
$597.52
|
| Rate for Payer: Anthem Medicaid |
$266.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$605.28
|
| Rate for Payer: Cash Price |
$388.00
|
| Rate for Payer: Cigna Commercial |
$644.08
|
| Rate for Payer: First Health Commercial |
$737.20
|
| Rate for Payer: Humana Commercial |
$659.60
|
| Rate for Payer: Humana KY Medicaid |
$266.87
|
| Rate for Payer: Kentucky WC Medicaid |
$269.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$636.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$272.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.88
|
| Rate for Payer: Ohio Health Group HMO |
$582.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.56
|
| Rate for Payer: PHCS Commercial |
$744.96
|
| Rate for Payer: United Healthcare All Payer |
$682.88
|
|
|
GUIDWIR SHT TAPR .018*190 J1.5
|
Facility
|
IP
|
$1,717.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$223.28 |
| Max. Negotiated Rate |
$1,648.80 |
| Rate for Payer: Aetna Commercial |
$1,322.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,339.65
|
| Rate for Payer: Cash Price |
$858.75
|
| Rate for Payer: Cigna Commercial |
$1,425.52
|
| Rate for Payer: First Health Commercial |
$1,631.62
|
| Rate for Payer: Humana Commercial |
$1,459.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$223.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$532.42
|
| Rate for Payer: PHCS Commercial |
$1,648.80
|
| Rate for Payer: United Healthcare All Payer |
$1,511.40
|
|
|
GUIDWIR SHT TAPR .018*190 J1.5
|
Facility
|
OP
|
$1,717.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$223.28 |
| Max. Negotiated Rate |
$1,648.80 |
| Rate for Payer: Aetna Commercial |
$1,322.48
|
| Rate for Payer: Anthem Medicaid |
$590.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,339.65
|
| Rate for Payer: Cash Price |
$858.75
|
| Rate for Payer: Cigna Commercial |
$1,425.52
|
| Rate for Payer: First Health Commercial |
$1,631.62
|
| Rate for Payer: Humana Commercial |
$1,459.88
|
| Rate for Payer: Humana KY Medicaid |
$590.65
|
| Rate for Payer: Kentucky WC Medicaid |
$596.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$602.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$223.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$532.42
|
| Rate for Payer: PHCS Commercial |
$1,648.80
|
| Rate for Payer: United Healthcare All Payer |
$1,511.40
|
|
|
GUIDWIR SM VESSEL .025*150 STR
|
Facility
|
OP
|
$799.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.98 |
| Max. Negotiated Rate |
$767.88 |
| Rate for Payer: Aetna Commercial |
$615.90
|
| Rate for Payer: Anthem Medicaid |
$275.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$623.90
|
| Rate for Payer: Cash Price |
$399.94
|
| Rate for Payer: Cigna Commercial |
$663.89
|
| Rate for Payer: First Health Commercial |
$759.88
|
| Rate for Payer: Humana Commercial |
$679.89
|
| Rate for Payer: Humana KY Medicaid |
$275.08
|
| Rate for Payer: Kentucky WC Medicaid |
$277.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$655.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$703.89
|
| Rate for Payer: Ohio Health Group HMO |
$599.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.96
|
| Rate for Payer: PHCS Commercial |
$767.88
|
| Rate for Payer: United Healthcare All Payer |
$703.89
|
|
|
GUIDWIR SM VESSEL .025*150 STR
|
Facility
|
IP
|
$799.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.98 |
| Max. Negotiated Rate |
$767.88 |
| Rate for Payer: Aetna Commercial |
$615.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$623.90
|
| Rate for Payer: Cash Price |
$399.94
|
| Rate for Payer: Cigna Commercial |
$663.89
|
| Rate for Payer: First Health Commercial |
$759.88
|
| Rate for Payer: Humana Commercial |
$679.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$655.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$703.89
|
| Rate for Payer: Ohio Health Group HMO |
$599.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.96
|
| Rate for Payer: PHCS Commercial |
$767.88
|
| Rate for Payer: United Healthcare All Payer |
$703.89
|
|
|
GUIDWIR W/TROCR TIP DIA 1.35MM
|
Facility
|
IP
|
$467.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$60.76 |
| Max. Negotiated Rate |
$448.68 |
| Rate for Payer: Aetna Commercial |
$359.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$364.56
|
| Rate for Payer: Cash Price |
$233.69
|
| Rate for Payer: Cigna Commercial |
$387.93
|
| Rate for Payer: First Health Commercial |
$444.01
|
| Rate for Payer: Humana Commercial |
$397.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$383.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$411.29
|
| Rate for Payer: Ohio Health Group HMO |
$350.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$144.89
|
| Rate for Payer: PHCS Commercial |
$448.68
|
| Rate for Payer: United Healthcare All Payer |
$411.29
|
|
|
GUIDWIR W/TROCR TIP DIA 1.35MM
|
Facility
|
OP
|
$467.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$60.76 |
| Max. Negotiated Rate |
$448.68 |
| Rate for Payer: Aetna Commercial |
$359.88
|
| Rate for Payer: Anthem Medicaid |
$160.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$364.56
|
| Rate for Payer: Cash Price |
$233.69
|
| Rate for Payer: Cigna Commercial |
$387.93
|
| Rate for Payer: First Health Commercial |
$444.01
|
| Rate for Payer: Humana Commercial |
$397.27
|
| Rate for Payer: Humana KY Medicaid |
$160.73
|
| Rate for Payer: Kentucky WC Medicaid |
$162.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$383.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$163.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$411.29
|
| Rate for Payer: Ohio Health Group HMO |
$350.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$144.89
|
| Rate for Payer: PHCS Commercial |
$448.68
|
| Rate for Payer: United Healthcare All Payer |
$411.29
|
|
|
GUNTHER TULIP VENA CAVA FILTER
|
Facility
|
OP
|
$6,796.75
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$883.58 |
| Max. Negotiated Rate |
$6,524.88 |
| Rate for Payer: Aetna Commercial |
$5,233.50
|
| Rate for Payer: Anthem Medicaid |
$2,337.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,301.46
|
| Rate for Payer: Cash Price |
$3,398.38
|
| Rate for Payer: Cigna Commercial |
$5,641.30
|
| Rate for Payer: First Health Commercial |
$6,456.91
|
| Rate for Payer: Humana Commercial |
$5,777.24
|
| Rate for Payer: Humana KY Medicaid |
$2,337.40
|
| Rate for Payer: Kentucky WC Medicaid |
$2,361.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,573.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,016.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,039.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,384.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,981.14
|
| Rate for Payer: Ohio Health Group HMO |
$5,097.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,359.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,106.99
|
| Rate for Payer: PHCS Commercial |
$6,524.88
|
| Rate for Payer: United Healthcare All Payer |
$5,981.14
|
|
|
GUNTHER TULIP VENA CAVA FILTER
|
Facility
|
IP
|
$6,796.75
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$883.58 |
| Max. Negotiated Rate |
$6,524.88 |
| Rate for Payer: Aetna Commercial |
$5,233.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,301.46
|
| Rate for Payer: Cash Price |
$3,398.38
|
| Rate for Payer: Cigna Commercial |
$5,641.30
|
| Rate for Payer: First Health Commercial |
$6,456.91
|
| Rate for Payer: Humana Commercial |
$5,777.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,573.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,016.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,039.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,981.14
|
| Rate for Payer: Ohio Health Group HMO |
$5,097.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,359.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,106.99
|
| Rate for Payer: PHCS Commercial |
$6,524.88
|
| Rate for Payer: United Healthcare All Payer |
$5,981.14
|
|
|
GYNE LOTRIMIN(CLOTRIM) 1% 45GM
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 61269022041
|
| Hospital Charge Code |
25000742
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Anthem Medicaid |
$0.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.47
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.50
|
| Rate for Payer: First Health Commercial |
$0.57
|
| Rate for Payer: Humana Commercial |
$0.51
|
| Rate for Payer: Humana KY Medicaid |
$0.21
|
| Rate for Payer: Kentucky WC Medicaid |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.53
|
| Rate for Payer: Ohio Health Group HMO |
$0.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.19
|
| Rate for Payer: PHCS Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Payer |
$0.53
|
| Rate for Payer: Aetna Commercial |
$0.46
|
|
|
GYNE LOTRIMIN(CLOTRIM) 1% 45GM
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 61269022041
|
| Hospital Charge Code |
25000742
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna Commercial |
$0.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.47
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.50
|
| Rate for Payer: First Health Commercial |
$0.57
|
| Rate for Payer: Humana Commercial |
$0.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.53
|
| Rate for Payer: Ohio Health Group HMO |
$0.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.19
|
| Rate for Payer: PHCS Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Payer |
$0.53
|
|
|
HALAVEN 0.1MG(1MG/2ML VIA;)
|
Facility
|
OP
|
$7,684.50
|
|
|
Service Code
|
HCPCS J9179
|
| Hospital Charge Code |
25002610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.02 |
| Max. Negotiated Rate |
$7,377.12 |
| Rate for Payer: Aetna Commercial |
$5,917.06
|
| Rate for Payer: Anthem Medicaid |
$2,642.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$134.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,993.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$187.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$180.92
|
| Rate for Payer: Cash Price |
$3,842.25
|
| Rate for Payer: Cash Price |
$3,842.25
|
| Rate for Payer: Cigna Commercial |
$6,378.14
|
| Rate for Payer: First Health Commercial |
$7,300.28
|
| Rate for Payer: Humana Commercial |
$6,531.82
|
| Rate for Payer: Humana KY Medicaid |
$2,642.70
|
| Rate for Payer: Humana Medicare Advantage |
$134.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,669.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,301.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,671.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,695.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,762.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,763.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,536.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$998.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,382.20
|
| Rate for Payer: PHCS Commercial |
$7,377.12
|
| Rate for Payer: United Healthcare All Payer |
$6,762.36
|
|
|
HALAVEN 0.1MG(1MG/2ML VIA;)
|
Facility
|
IP
|
$7,684.50
|
|
|
Service Code
|
HCPCS J9179
|
| Hospital Charge Code |
25002610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$998.98 |
| Max. Negotiated Rate |
$7,377.12 |
| Rate for Payer: Aetna Commercial |
$5,917.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,993.91
|
| Rate for Payer: Cash Price |
$3,842.25
|
| Rate for Payer: Cigna Commercial |
$6,378.14
|
| Rate for Payer: First Health Commercial |
$7,300.28
|
| Rate for Payer: Humana Commercial |
$6,531.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,301.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,671.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,305.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,762.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,763.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,536.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$998.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,382.20
|
| Rate for Payer: PHCS Commercial |
$7,377.12
|
| Rate for Payer: United Healthcare All Payer |
$6,762.36
|
|
|
HALDOL CONC(HALOPERI 5MG/2.5ML
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 121058104
|
| Hospital Charge Code |
25000748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
HALDOL CONC(HALOPERI 5MG/2.5ML
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 121058104
|
| Hospital Charge Code |
25000748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
HALDOL DECAN EQ50MG 100MG/ML V
|
Facility
|
IP
|
$320.48
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
25002123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.66 |
| Max. Negotiated Rate |
$307.66 |
| Rate for Payer: Aetna Commercial |
$246.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.97
|
| Rate for Payer: Cash Price |
$160.24
|
| Rate for Payer: Cigna Commercial |
$266.00
|
| Rate for Payer: First Health Commercial |
$304.46
|
| Rate for Payer: Humana Commercial |
$272.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.02
|
| Rate for Payer: Ohio Health Group HMO |
$240.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.35
|
| Rate for Payer: PHCS Commercial |
$307.66
|
| Rate for Payer: United Healthcare All Payer |
$282.02
|
|
|
HALDOL DECAN EQ50MG 100MG/ML V
|
Facility
|
OP
|
$320.48
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
25002123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.66 |
| Max. Negotiated Rate |
$307.66 |
| Rate for Payer: Aetna Commercial |
$246.77
|
| Rate for Payer: Anthem Medicaid |
$110.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.97
|
| Rate for Payer: Cash Price |
$160.24
|
| Rate for Payer: Cigna Commercial |
$266.00
|
| Rate for Payer: First Health Commercial |
$304.46
|
| Rate for Payer: Humana Commercial |
$272.41
|
| Rate for Payer: Humana KY Medicaid |
$110.21
|
| Rate for Payer: Kentucky WC Medicaid |
$111.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.02
|
| Rate for Payer: Ohio Health Group HMO |
$240.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.35
|
| Rate for Payer: PHCS Commercial |
$307.66
|
| Rate for Payer: United Healthcare All Payer |
$282.02
|
|
|
HALDOL (HALOPERIDOL) 1MG/1TAB
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 378025701
|
| Hospital Charge Code |
25000744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
HALDOL (HALOPERIDOL) 1MG/1TAB
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 378025701
|
| Hospital Charge Code |
25000744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
HALDOL (HALOPERIDOL) 2MG/1TAB
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
NDC 51079073520
|
| Hospital Charge Code |
25000745
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: First Health Commercial |
$4.52
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.19
|
| Rate for Payer: Ohio Health Group HMO |
$3.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
|
|
HALDOL (HALOPERIDOL) 2MG/1TAB
|
Facility
|
IP
|
$4.76
|
|
|
Service Code
|
NDC 51079073520
|
| Hospital Charge Code |
25000745
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: First Health Commercial |
$4.52
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.19
|
| Rate for Payer: Ohio Health Group HMO |
$3.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
|
|
HALDOL (HALOPERIDOL) 5MG/1TAB
|
Facility
|
OP
|
$4.82
|
|
|
Service Code
|
NDC 68382007901
|
| Hospital Charge Code |
25000746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Cash Price |
$2.41
|
| Rate for Payer: Cigna Commercial |
$4.00
|
| Rate for Payer: First Health Commercial |
$4.58
|
| Rate for Payer: Humana Commercial |
$4.10
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.24
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
|
HALDOL (HALOPERIDOL) 5MG/1TAB
|
Facility
|
IP
|
$4.82
|
|
|
Service Code
|
NDC 68382007901
|
| Hospital Charge Code |
25000746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Cash Price |
$2.41
|
| Rate for Payer: Cigna Commercial |
$4.00
|
| Rate for Payer: First Health Commercial |
$4.58
|
| Rate for Payer: Humana Commercial |
$4.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.24
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
