|
MATRISTEM MATRIX XS 5CM*5CM
|
Facility
|
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
MATRISTEM MATRIX XS 5CM*5CM
|
Facility
|
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem Medicaid |
$1,659.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Humana KY Medicaid |
$1,659.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
MATRISTEM MATRIX XS 6CM*15CM
|
Facility
|
OP
|
$13,155.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,710.15 |
| Max. Negotiated Rate |
$12,628.80 |
| Rate for Payer: Aetna Commercial |
$10,129.35
|
| Rate for Payer: Anthem Medicaid |
$4,524.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,260.90
|
| Rate for Payer: Cash Price |
$6,577.50
|
| Rate for Payer: Cigna Commercial |
$10,918.65
|
| Rate for Payer: First Health Commercial |
$12,497.25
|
| Rate for Payer: Humana Commercial |
$11,181.75
|
| Rate for Payer: Humana KY Medicaid |
$4,524.00
|
| Rate for Payer: Kentucky WC Medicaid |
$4,570.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,787.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,708.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,946.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,614.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,576.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,866.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,631.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,710.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,078.05
|
| Rate for Payer: PHCS Commercial |
$12,628.80
|
| Rate for Payer: United Healthcare All Payer |
$11,576.40
|
|
|
MATRISTEM MATRIX XS 6CM*15CM
|
Facility
|
IP
|
$13,155.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,710.15 |
| Max. Negotiated Rate |
$12,628.80 |
| Rate for Payer: Aetna Commercial |
$10,129.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,260.90
|
| Rate for Payer: Cash Price |
$6,577.50
|
| Rate for Payer: Cigna Commercial |
$10,918.65
|
| Rate for Payer: First Health Commercial |
$12,497.25
|
| Rate for Payer: Humana Commercial |
$11,181.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,787.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,708.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,946.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,576.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,866.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,631.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,710.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,078.05
|
| Rate for Payer: PHCS Commercial |
$12,628.80
|
| Rate for Payer: United Healthcare All Payer |
$11,576.40
|
|
|
MATRISTEM MATRIX XS 7CM*10CM
|
Facility
|
IP
|
$10,965.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
MATRISTEM MATRIX XS 7CM*10CM
|
Facility
|
OP
|
$10,965.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem Medicaid |
$3,770.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Humana KY Medicaid |
$3,770.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,809.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,846.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
MATRISTEM MATRIX XS 8CM*16CM
|
Facility
|
OP
|
$18,024.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,343.12 |
| Max. Negotiated Rate |
$17,303.04 |
| Rate for Payer: Aetna Commercial |
$13,878.48
|
| Rate for Payer: Anthem Medicaid |
$6,198.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,058.72
|
| Rate for Payer: Cash Price |
$9,012.00
|
| Rate for Payer: Cigna Commercial |
$14,959.92
|
| Rate for Payer: First Health Commercial |
$17,122.80
|
| Rate for Payer: Humana Commercial |
$15,320.40
|
| Rate for Payer: Humana KY Medicaid |
$6,198.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,261.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,779.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,301.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,407.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,322.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,861.12
|
| Rate for Payer: Ohio Health Group HMO |
$13,518.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,343.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,587.44
|
| Rate for Payer: PHCS Commercial |
$17,303.04
|
| Rate for Payer: United Healthcare All Payer |
$15,861.12
|
|
|
MATRISTEM MATRIX XS 8CM*16CM
|
Facility
|
IP
|
$18,024.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,343.12 |
| Max. Negotiated Rate |
$17,303.04 |
| Rate for Payer: Aetna Commercial |
$13,878.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,058.72
|
| Rate for Payer: Cash Price |
$9,012.00
|
| Rate for Payer: Cigna Commercial |
$14,959.92
|
| Rate for Payer: First Health Commercial |
$17,122.80
|
| Rate for Payer: Humana Commercial |
$15,320.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,779.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,301.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,407.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,861.12
|
| Rate for Payer: Ohio Health Group HMO |
$13,518.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,343.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,587.44
|
| Rate for Payer: PHCS Commercial |
$17,303.04
|
| Rate for Payer: United Healthcare All Payer |
$15,861.12
|
|
|
MAVIK (TRANDOLAPRIL) 1MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68180056601
|
| Hospital Charge Code |
25003876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| 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 |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| 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 |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 1MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68180056601
|
| Hospital Charge Code |
25003876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| 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 |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| 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 |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68180056801
|
| Hospital Charge Code |
25000945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| 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 |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| 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 |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68180056701
|
| Hospital Charge Code |
25000944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| 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 |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| 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 |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68180056801
|
| Hospital Charge Code |
25000945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| 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 |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| 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 |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68180056701
|
| Hospital Charge Code |
25000944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| 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 |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| 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 |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAXALT-MLT(RIZATRIPTAN)10 MG T
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 65862062690
|
| Hospital Charge Code |
25000948
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
|
|
MAXALT-MLT(RIZATRIPTAN)10 MG T
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 65862062690
|
| Hospital Charge Code |
25000948
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXALT-MLT(RIZATRIPTAN) 5MGTAB
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 65862062590
|
| Hospital Charge Code |
25000947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXALT-MLT(RIZATRIPTAN) 5MGTAB
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 65862062590
|
| Hospital Charge Code |
25000947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXIMO II VR D284VRC
|
Facility
|
IP
|
$79,900.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
27000004
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,387.00 |
| Max. Negotiated Rate |
$76,704.00 |
| Rate for Payer: Aetna Commercial |
$61,523.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62,322.00
|
| Rate for Payer: Cash Price |
$39,950.00
|
| Rate for Payer: Cigna Commercial |
$66,317.00
|
| Rate for Payer: First Health Commercial |
$75,905.00
|
| Rate for Payer: Humana Commercial |
$67,915.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65,518.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58,966.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,970.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$70,312.00
|
| Rate for Payer: Ohio Health Group HMO |
$59,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,980.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,387.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,769.00
|
| Rate for Payer: PHCS Commercial |
$76,704.00
|
| Rate for Payer: United Healthcare All Payer |
$70,312.00
|
|
|
MAXIMO II VR D284VRC
|
Facility
|
OP
|
$79,900.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
27000004
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,387.00 |
| Max. Negotiated Rate |
$76,704.00 |
| Rate for Payer: Aetna Commercial |
$61,523.00
|
| Rate for Payer: Anthem Medicaid |
$27,477.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62,322.00
|
| Rate for Payer: Cash Price |
$39,950.00
|
| Rate for Payer: Cigna Commercial |
$66,317.00
|
| Rate for Payer: First Health Commercial |
$75,905.00
|
| Rate for Payer: Humana Commercial |
$67,915.00
|
| Rate for Payer: Humana KY Medicaid |
$27,477.61
|
| Rate for Payer: Kentucky WC Medicaid |
$27,757.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65,518.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58,966.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,970.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,028.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$70,312.00
|
| Rate for Payer: Ohio Health Group HMO |
$59,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,980.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,387.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,769.00
|
| Rate for Payer: PHCS Commercial |
$76,704.00
|
| Rate for Payer: United Healthcare All Payer |
$70,312.00
|
|
|
MAXIPIME 1 GM/ 3.6 ML
|
Facility
|
IP
|
$73.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$70.85 |
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$61.25
|
| Rate for Payer: First Health Commercial |
$70.11
|
| Rate for Payer: Humana Commercial |
$62.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.94
|
| Rate for Payer: Ohio Health Group HMO |
$55.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.88
|
| Rate for Payer: PHCS Commercial |
$70.85
|
| Rate for Payer: United Healthcare All Payer |
$64.94
|
|
|
MAXIPIME 1 GM/ 3.6 ML
|
Facility
|
OP
|
$73.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$70.85 |
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Anthem Medicaid |
$25.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$61.25
|
| Rate for Payer: First Health Commercial |
$70.11
|
| Rate for Payer: Humana Commercial |
$62.73
|
| Rate for Payer: Humana KY Medicaid |
$25.38
|
| Rate for Payer: Kentucky WC Medicaid |
$25.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.94
|
| Rate for Payer: Ohio Health Group HMO |
$55.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.88
|
| Rate for Payer: PHCS Commercial |
$70.85
|
| Rate for Payer: United Healthcare All Payer |
$64.94
|
|
|
MAXIPIME 2GM/20ML VIAL
|
Facility
|
IP
|
$121.13
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.48
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.54
|
| Rate for Payer: First Health Commercial |
$115.07
|
| Rate for Payer: Humana Commercial |
$102.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.55
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
MAXIPIME 2GM/20ML VIAL
|
Facility
|
OP
|
$121.13
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.27
|
| Rate for Payer: Anthem Medicaid |
$41.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.48
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.54
|
| Rate for Payer: First Health Commercial |
$115.07
|
| Rate for Payer: Humana Commercial |
$102.96
|
| Rate for Payer: Humana KY Medicaid |
$41.66
|
| Rate for Payer: Kentucky WC Medicaid |
$42.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.55
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
MAXIPIME 500 MG (1 GRAM VIAL)
|
Facility
|
IP
|
$112.05
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.74
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
