|
MACROBID (NITROFURA 100MG/1CAP
|
Facility
|
IP
|
$10.60
|
|
|
Service Code
|
NDC 50268062515
|
| Hospital Charge Code |
25000937
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$10.18 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.27
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna Commercial |
$8.80
|
| Rate for Payer: First Health Commercial |
$10.07
|
| Rate for Payer: Humana Commercial |
$9.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.29
|
| Rate for Payer: PHCS Commercial |
$10.18
|
| Rate for Payer: United Healthcare All Payer |
$9.33
|
|
|
MACROBID (NITROFURA 100MG/1CAP
|
Facility
|
OP
|
$10.60
|
|
|
Service Code
|
NDC 50268062515
|
| Hospital Charge Code |
25000937
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$10.18 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Anthem Medicaid |
$3.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.27
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna Commercial |
$8.80
|
| Rate for Payer: First Health Commercial |
$10.07
|
| Rate for Payer: Humana Commercial |
$9.01
|
| Rate for Payer: Humana KY Medicaid |
$3.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.29
|
| Rate for Payer: PHCS Commercial |
$10.18
|
| Rate for Payer: United Healthcare All Payer |
$9.33
|
|
|
MACRODANTIN 50MG CAPSULE
|
Facility
|
OP
|
$9.01
|
|
|
Service Code
|
NDC 57664023288
|
| Hospital Charge Code |
25003195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.65 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.03
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.48
|
| Rate for Payer: First Health Commercial |
$8.56
|
| Rate for Payer: Humana Commercial |
$7.66
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.93
|
| Rate for Payer: Ohio Health Group HMO |
$6.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.79
|
| Rate for Payer: PHCS Commercial |
$8.65
|
| Rate for Payer: United Healthcare All Payer |
$7.93
|
|
|
MACRODANTIN 50MG CAPSULE
|
Facility
|
IP
|
$9.01
|
|
|
Service Code
|
NDC 57664023288
|
| Hospital Charge Code |
25003195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.65 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.03
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.48
|
| Rate for Payer: First Health Commercial |
$8.56
|
| Rate for Payer: Humana Commercial |
$7.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.93
|
| Rate for Payer: Ohio Health Group HMO |
$6.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.79
|
| Rate for Payer: PHCS Commercial |
$8.65
|
| Rate for Payer: United Healthcare All Payer |
$7.93
|
|
|
MACROSCOPIC ID ARTHROPOD
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
HCPCS 87168
|
| Hospital Charge Code |
30001312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$84.48 |
| Rate for Payer: Aetna Commercial |
$67.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.66
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna Commercial |
$73.04
|
| Rate for Payer: First Health Commercial |
$83.60
|
| Rate for Payer: Humana Commercial |
$74.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.44
|
| Rate for Payer: Ohio Health Group HMO |
$66.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.28
|
| Rate for Payer: PHCS Commercial |
$84.48
|
| Rate for Payer: United Healthcare All Payer |
$77.44
|
|
|
MACROSCOPIC ID ARTHROPOD
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
HCPCS 87168
|
| Hospital Charge Code |
30001312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$84.48 |
| Rate for Payer: Aetna Commercial |
$67.76
|
| Rate for Payer: Anthem Medicaid |
$4.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna Commercial |
$73.04
|
| Rate for Payer: First Health Commercial |
$83.60
|
| Rate for Payer: Humana Commercial |
$74.80
|
| Rate for Payer: Humana KY Medicaid |
$4.27
|
| Rate for Payer: Humana Medicare Advantage |
$4.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.44
|
| Rate for Payer: Ohio Health Group HMO |
$66.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.28
|
| Rate for Payer: PHCS Commercial |
$84.48
|
| Rate for Payer: United Healthcare All Payer |
$77.44
|
|
|
MAGIC MOUTHWASH SUSP
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003197
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
MAGIC MOUTHWASH SUSP
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003197
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
MAGNESIUM 20GM/1000ML D5/WMTR
|
Facility
|
OP
|
$120.56
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002434
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.67 |
| Max. Negotiated Rate |
$115.74 |
| Rate for Payer: Aetna Commercial |
$92.83
|
| Rate for Payer: Aetna Commercial |
$93.12
|
| Rate for Payer: Anthem Medicaid |
$41.46
|
| Rate for Payer: Anthem Medicaid |
$41.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.33
|
| Rate for Payer: Cash Price |
$60.28
|
| Rate for Payer: Cash Price |
$60.47
|
| Rate for Payer: Cigna Commercial |
$100.37
|
| Rate for Payer: Cigna Commercial |
$100.06
|
| Rate for Payer: First Health Commercial |
$114.88
|
| Rate for Payer: First Health Commercial |
$114.53
|
| Rate for Payer: Humana Commercial |
$102.48
|
| Rate for Payer: Humana Commercial |
$102.79
|
| Rate for Payer: Humana KY Medicaid |
$41.46
|
| Rate for Payer: Humana KY Medicaid |
$41.59
|
| Rate for Payer: Kentucky WC Medicaid |
$42.01
|
| Rate for Payer: Kentucky WC Medicaid |
$41.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.42
|
| Rate for Payer: Ohio Health Group HMO |
$90.42
|
| Rate for Payer: Ohio Health Group HMO |
$90.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.49
|
| Rate for Payer: PHCS Commercial |
$116.09
|
| Rate for Payer: PHCS Commercial |
$115.74
|
| Rate for Payer: United Healthcare All Payer |
$106.42
|
| Rate for Payer: United Healthcare All Payer |
$106.09
|
|
|
MAGNESIUM 20GM/1000ML D5/WMTR
|
Facility
|
IP
|
$120.56
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002434
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.67 |
| Max. Negotiated Rate |
$115.74 |
| Rate for Payer: Aetna Commercial |
$92.83
|
| Rate for Payer: Aetna Commercial |
$93.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.33
|
| Rate for Payer: Cash Price |
$60.28
|
| Rate for Payer: Cash Price |
$60.47
|
| Rate for Payer: Cigna Commercial |
$100.06
|
| Rate for Payer: Cigna Commercial |
$100.37
|
| Rate for Payer: First Health Commercial |
$114.88
|
| Rate for Payer: First Health Commercial |
$114.53
|
| Rate for Payer: Humana Commercial |
$102.79
|
| Rate for Payer: Humana Commercial |
$102.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.42
|
| Rate for Payer: Ohio Health Group HMO |
$90.42
|
| Rate for Payer: Ohio Health Group HMO |
$90.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.37
|
| Rate for Payer: PHCS Commercial |
$115.74
|
| Rate for Payer: PHCS Commercial |
$116.09
|
| Rate for Payer: United Healthcare All Payer |
$106.09
|
| Rate for Payer: United Healthcare All Payer |
$106.42
|
|
|
MAGNESIUM 2GM IVPB (500MGV)
|
Facility
|
IP
|
$113.78
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$109.23 |
| Rate for Payer: Aetna Commercial |
$87.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.75
|
| Rate for Payer: Cash Price |
$56.89
|
| Rate for Payer: Cigna Commercial |
$94.44
|
| Rate for Payer: First Health Commercial |
$108.09
|
| Rate for Payer: Humana Commercial |
$96.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.13
|
| Rate for Payer: Ohio Health Group HMO |
$85.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.27
|
| Rate for Payer: PHCS Commercial |
$109.23
|
| Rate for Payer: United Healthcare All Payer |
$100.13
|
|
|
MAGNESIUM 2GM IVPB (500MGV)
|
Facility
|
OP
|
$113.78
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$109.23 |
| Rate for Payer: Aetna Commercial |
$87.61
|
| Rate for Payer: Anthem Medicaid |
$39.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.75
|
| Rate for Payer: Cash Price |
$56.89
|
| Rate for Payer: Cigna Commercial |
$94.44
|
| Rate for Payer: First Health Commercial |
$108.09
|
| Rate for Payer: Humana Commercial |
$96.71
|
| Rate for Payer: Humana KY Medicaid |
$39.13
|
| Rate for Payer: Kentucky WC Medicaid |
$39.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.13
|
| Rate for Payer: Ohio Health Group HMO |
$85.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.27
|
| Rate for Payer: PHCS Commercial |
$109.23
|
| Rate for Payer: United Healthcare All Payer |
$100.13
|
|
|
MAGNESIUM 4GM/50ML IVPB
|
Facility
|
OP
|
$115.11
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25003198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$110.51 |
| Rate for Payer: Aetna Commercial |
$88.63
|
| Rate for Payer: Anthem Medicaid |
$39.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.79
|
| Rate for Payer: Cash Price |
$57.56
|
| Rate for Payer: Cigna Commercial |
$95.54
|
| Rate for Payer: First Health Commercial |
$109.35
|
| Rate for Payer: Humana Commercial |
$97.84
|
| Rate for Payer: Humana KY Medicaid |
$39.59
|
| Rate for Payer: Kentucky WC Medicaid |
$39.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.30
|
| Rate for Payer: Ohio Health Group HMO |
$86.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.68
|
| Rate for Payer: PHCS Commercial |
$110.51
|
| Rate for Payer: United Healthcare All Payer |
$101.30
|
|
|
MAGNESIUM 4GM/50ML IVPB
|
Facility
|
IP
|
$115.11
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25003198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$110.51 |
| Rate for Payer: Aetna Commercial |
$88.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.79
|
| Rate for Payer: Cash Price |
$57.56
|
| Rate for Payer: Cigna Commercial |
$95.54
|
| Rate for Payer: First Health Commercial |
$109.35
|
| Rate for Payer: Humana Commercial |
$97.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.30
|
| Rate for Payer: Ohio Health Group HMO |
$86.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.68
|
| Rate for Payer: PHCS Commercial |
$110.51
|
| Rate for Payer: United Healthcare All Payer |
$101.30
|
|
|
MAGNESIUM 500MG [10GM/50ML]
|
Facility
|
OP
|
$122.29
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25003853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$117.40 |
| Rate for Payer: Aetna Commercial |
$94.16
|
| Rate for Payer: Anthem Medicaid |
$42.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.39
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: Cigna Commercial |
$101.50
|
| Rate for Payer: First Health Commercial |
$116.18
|
| Rate for Payer: Humana Commercial |
$103.95
|
| Rate for Payer: Humana KY Medicaid |
$42.06
|
| Rate for Payer: Kentucky WC Medicaid |
$42.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.62
|
| Rate for Payer: Ohio Health Group HMO |
$91.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.91
|
| Rate for Payer: PHCS Commercial |
$117.40
|
| Rate for Payer: United Healthcare All Payer |
$107.62
|
|
|
MAGNESIUM 500MG [10GM/50ML]
|
Facility
|
IP
|
$122.29
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25003853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$117.40 |
| Rate for Payer: Aetna Commercial |
$94.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.39
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: Cigna Commercial |
$101.50
|
| Rate for Payer: First Health Commercial |
$116.18
|
| Rate for Payer: Humana Commercial |
$103.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.62
|
| Rate for Payer: Ohio Health Group HMO |
$91.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.91
|
| Rate for Payer: PHCS Commercial |
$117.40
|
| Rate for Payer: United Healthcare All Payer |
$107.62
|
|
|
MAGNESIUM - BLOOD
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
30000449
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$61.44 |
| Rate for Payer: Aetna Commercial |
$49.28
|
| Rate for Payer: Anthem Medicaid |
$6.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.70
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cigna Commercial |
$53.12
|
| Rate for Payer: First Health Commercial |
$60.80
|
| Rate for Payer: Humana Commercial |
$54.40
|
| Rate for Payer: Humana KY Medicaid |
$6.70
|
| Rate for Payer: Humana Medicare Advantage |
$6.70
|
| Rate for Payer: Kentucky WC Medicaid |
$6.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.32
|
| Rate for Payer: Ohio Health Group HMO |
$48.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
| Rate for Payer: PHCS Commercial |
$61.44
|
| Rate for Payer: United Healthcare All Payer |
$56.32
|
|
|
MAGNESIUM - BLOOD
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
30000449
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$13.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$64.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cigna Commercial |
$6.00
|
| Rate for Payer: Healthspan PPO |
$6.05
|
| Rate for Payer: Multiplan PHCS |
$38.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.80
|
| Rate for Payer: UHCCP Medicaid |
$22.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$4.02
|
|
|
MAGNESIUM - BLOOD
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
30000449
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$61.44 |
| Rate for Payer: Aetna Commercial |
$49.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.39
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cigna Commercial |
$53.12
|
| Rate for Payer: First Health Commercial |
$60.80
|
| Rate for Payer: Humana Commercial |
$54.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.32
|
| Rate for Payer: Ohio Health Group HMO |
$48.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
| Rate for Payer: PHCS Commercial |
$61.44
|
| Rate for Payer: United Healthcare All Payer |
$56.32
|
|
|
MAGNESIUM CITRATE 10 OZ 10OZ
|
Facility
|
IP
|
$10.96
|
|
|
Service Code
|
NDC 869016638
|
| Hospital Charge Code |
25000938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$8.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.55
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cigna Commercial |
$9.10
|
| Rate for Payer: First Health Commercial |
$10.41
|
| Rate for Payer: Humana Commercial |
$9.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.64
|
| Rate for Payer: Ohio Health Group HMO |
$8.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.40
|
| Rate for Payer: PHCS Commercial |
$10.52
|
| Rate for Payer: United Healthcare All Payer |
$9.64
|
|
|
MAGNESIUM CITRATE 10 OZ 10OZ
|
Facility
|
OP
|
$10.96
|
|
|
Service Code
|
NDC 869016638
|
| Hospital Charge Code |
25000938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$8.44
|
| Rate for Payer: Anthem Medicaid |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.55
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cigna Commercial |
$9.10
|
| Rate for Payer: First Health Commercial |
$10.41
|
| Rate for Payer: Humana Commercial |
$9.32
|
| Rate for Payer: Humana KY Medicaid |
$3.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.64
|
| Rate for Payer: Ohio Health Group HMO |
$8.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.40
|
| Rate for Payer: PHCS Commercial |
$10.52
|
| Rate for Payer: United Healthcare All Payer |
$9.64
|
|
|
MAGNESIUM SULF 0.5GM[50% 5GM
|
Facility
|
IP
|
$78.17
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002437
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.04 |
| Rate for Payer: Aetna Commercial |
$60.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.97
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.88
|
| Rate for Payer: First Health Commercial |
$74.26
|
| Rate for Payer: Humana Commercial |
$66.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.79
|
| Rate for Payer: Ohio Health Group HMO |
$58.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.23
|
| Rate for Payer: PHCS Commercial |
$75.04
|
| Rate for Payer: United Healthcare All Payer |
$68.79
|
|
|
MAGNESIUM SULF 0.5GM[50% 5GM
|
Facility
|
OP
|
$78.17
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002437
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.04 |
| Rate for Payer: Aetna Commercial |
$60.19
|
| Rate for Payer: Anthem Medicaid |
$26.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.97
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.88
|
| Rate for Payer: First Health Commercial |
$74.26
|
| Rate for Payer: Humana Commercial |
$66.44
|
| Rate for Payer: Humana KY Medicaid |
$26.88
|
| Rate for Payer: Kentucky WC Medicaid |
$27.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.79
|
| Rate for Payer: Ohio Health Group HMO |
$58.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.23
|
| Rate for Payer: PHCS Commercial |
$75.04
|
| Rate for Payer: United Healthcare All Payer |
$68.79
|
|
|
MAGNESIUM SULF 6 GM/D5W 100ML
|
Facility
|
OP
|
$80.70
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002441
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$77.47 |
| Rate for Payer: Aetna Commercial |
$62.14
|
| Rate for Payer: Anthem Medicaid |
$27.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.95
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: First Health Commercial |
$76.66
|
| Rate for Payer: Humana Commercial |
$68.60
|
| Rate for Payer: Humana KY Medicaid |
$27.75
|
| Rate for Payer: Kentucky WC Medicaid |
$28.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.02
|
| Rate for Payer: Ohio Health Group HMO |
$60.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.02
|
| Rate for Payer: PHCS Commercial |
$77.47
|
| Rate for Payer: United Healthcare All Payer |
$71.02
|
|
|
MAGNESIUM SULF 6 GM/D5W 100ML
|
Facility
|
IP
|
$80.70
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
25002441
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$77.47 |
| Rate for Payer: Aetna Commercial |
$62.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.95
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: First Health Commercial |
$76.66
|
| Rate for Payer: Humana Commercial |
$68.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.02
|
| Rate for Payer: Ohio Health Group HMO |
$60.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.02
|
| Rate for Payer: PHCS Commercial |
$77.47
|
| Rate for Payer: United Healthcare All Payer |
$71.02
|
|
