|
METATARSECTOMY(P
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 28140
|
| Hospital Charge Code |
761P0988
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.41 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$700.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$219.41
|
| Rate for Payer: Anthem Medicaid |
$336.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$768.74
|
| Rate for Payer: Healthspan PPO |
$793.90
|
| Rate for Payer: Humana Medicaid |
$336.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$562.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$343.29
|
| Rate for Payer: Molina Healthcare Passport |
$336.56
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$230.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$339.93
|
|
|
METER DOSE INH INITIAL
|
Professional
|
Both
|
$227.00
|
|
| Hospital Charge Code |
41000113
|
|
Hospital Revenue Code
|
412
|
| Min. Negotiated Rate |
$79.45 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$227.00
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Multiplan PHCS |
$136.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$158.90
|
| Rate for Payer: UHCCP Medicaid |
$79.45
|
|
|
METER DOSE INH INITIAL
|
Facility
|
IP
|
$227.00
|
|
| Hospital Charge Code |
41000113
|
|
Hospital Revenue Code
|
412
|
| Min. Negotiated Rate |
$29.51 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$177.06
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.37
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
METER DOSE INH INITIAL
|
Facility
|
OP
|
$227.00
|
|
| Hospital Charge Code |
41000113
|
|
Hospital Revenue Code
|
412
|
| Min. Negotiated Rate |
$29.51 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem Medicaid |
$78.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$177.06
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Humana KY Medicaid |
$78.07
|
| Rate for Payer: Kentucky WC Medicaid |
$78.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$79.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.37
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
METER DOSE INH SUBSQ
|
Facility
|
OP
|
$227.00
|
|
| Hospital Charge Code |
41000114
|
|
Hospital Revenue Code
|
412
|
| Min. Negotiated Rate |
$29.51 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem Medicaid |
$78.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$177.06
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Humana KY Medicaid |
$78.07
|
| Rate for Payer: Kentucky WC Medicaid |
$78.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$79.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.37
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
METER DOSE INH SUBSQ
|
Professional
|
Both
|
$227.00
|
|
| Hospital Charge Code |
41000114
|
|
Hospital Revenue Code
|
412
|
| Min. Negotiated Rate |
$79.45 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$227.00
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Multiplan PHCS |
$136.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$158.90
|
| Rate for Payer: UHCCP Medicaid |
$79.45
|
|
|
METER DOSE INH SUBSQ
|
Facility
|
IP
|
$227.00
|
|
| Hospital Charge Code |
41000114
|
|
Hospital Revenue Code
|
412
|
| Min. Negotiated Rate |
$29.51 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$177.06
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.37
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
METHADONE 10MG TABLET
|
Facility
|
IP
|
$60.10
|
|
|
Service Code
|
NDC 67877011601
|
| Hospital Charge Code |
25000968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.70 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.88
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cigna Commercial |
$49.88
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.89
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.63
|
| Rate for Payer: PHCS Commercial |
$57.70
|
| Rate for Payer: United Healthcare All Payer |
$52.89
|
|
|
METHADONE 10MG TABLET
|
Facility
|
OP
|
$60.10
|
|
|
Service Code
|
NDC 67877011601
|
| Hospital Charge Code |
25000968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.70 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem Medicaid |
$20.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.88
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cigna Commercial |
$49.88
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.08
|
| Rate for Payer: Humana KY Medicaid |
$20.67
|
| Rate for Payer: Kentucky WC Medicaid |
$20.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.89
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.63
|
| Rate for Payer: PHCS Commercial |
$57.70
|
| Rate for Payer: United Healthcare All Payer |
$52.89
|
|
|
METHADONE 40MG/4ML ORAL LIQ
|
Facility
|
IP
|
$62.70
|
|
|
Service Code
|
NDC 527192736
|
| Hospital Charge Code |
25004474
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.15 |
| Max. Negotiated Rate |
$60.19 |
| Rate for Payer: Aetna Commercial |
$48.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.91
|
| Rate for Payer: Cash Price |
$31.35
|
| Rate for Payer: Cigna Commercial |
$52.04
|
| Rate for Payer: First Health Commercial |
$59.56
|
| Rate for Payer: Humana Commercial |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.18
|
| Rate for Payer: Ohio Health Group HMO |
$47.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.44
|
| Rate for Payer: PHCS Commercial |
$60.19
|
| Rate for Payer: United Healthcare All Payer |
$55.18
|
|
|
METHADONE 40MG/4ML ORAL LIQ
|
Facility
|
OP
|
$62.70
|
|
|
Service Code
|
NDC 527192736
|
| Hospital Charge Code |
25004474
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.15 |
| Max. Negotiated Rate |
$60.19 |
| Rate for Payer: Anthem Medicaid |
$21.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.91
|
| Rate for Payer: Cash Price |
$31.35
|
| Rate for Payer: Cigna Commercial |
$52.04
|
| Rate for Payer: First Health Commercial |
$59.56
|
| Rate for Payer: Humana Commercial |
$53.30
|
| Rate for Payer: Humana KY Medicaid |
$21.56
|
| Rate for Payer: Kentucky WC Medicaid |
$21.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.18
|
| Rate for Payer: Ohio Health Group HMO |
$47.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.44
|
| Rate for Payer: PHCS Commercial |
$60.19
|
| Rate for Payer: United Healthcare All Payer |
$55.18
|
| Rate for Payer: Aetna Commercial |
$48.28
|
|
|
METHADONE 40MG TABLET SOL
|
Facility
|
OP
|
$60.26
|
|
|
Service Code
|
NDC 406054034
|
| Hospital Charge Code |
25000970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$57.85 |
| Rate for Payer: Aetna Commercial |
$46.40
|
| Rate for Payer: Anthem Medicaid |
$20.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cigna Commercial |
$50.02
|
| Rate for Payer: First Health Commercial |
$57.25
|
| Rate for Payer: Humana Commercial |
$51.22
|
| Rate for Payer: Humana KY Medicaid |
$20.72
|
| Rate for Payer: Kentucky WC Medicaid |
$20.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.03
|
| Rate for Payer: Ohio Health Group HMO |
$45.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.68
|
| Rate for Payer: PHCS Commercial |
$57.85
|
| Rate for Payer: United Healthcare All Payer |
$53.03
|
|
|
METHADONE 40MG TABLET SOL
|
Facility
|
IP
|
$60.26
|
|
|
Service Code
|
NDC 406054034
|
| Hospital Charge Code |
25000970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$57.85 |
| Rate for Payer: Humana Commercial |
$51.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.03
|
| Rate for Payer: Ohio Health Group HMO |
$45.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.68
|
| Rate for Payer: PHCS Commercial |
$57.85
|
| Rate for Payer: United Healthcare All Payer |
$53.03
|
| Rate for Payer: Aetna Commercial |
$46.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cigna Commercial |
$50.02
|
| Rate for Payer: First Health Commercial |
$57.25
|
|
|
METHEMOGLOBIN QUANT
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 83050
|
| Hospital Charge Code |
30000364
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$8.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.20
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$8.20
|
| Rate for Payer: Humana Medicare Advantage |
$8.20
|
| Rate for Payer: Kentucky WC Medicaid |
$8.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
METHEMOGLOBIN QUANT
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 83050
|
| Hospital Charge Code |
30000364
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
METHERGINE(METHYLERG .2MG/1TAB
|
Facility
|
OP
|
$125.78
|
|
|
Service Code
|
NDC 54063905
|
| Hospital Charge Code |
25000971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$120.75 |
| Rate for Payer: Aetna Commercial |
$96.85
|
| Rate for Payer: Anthem Medicaid |
$43.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.11
|
| Rate for Payer: Cash Price |
$62.89
|
| Rate for Payer: Cigna Commercial |
$104.40
|
| Rate for Payer: First Health Commercial |
$119.49
|
| Rate for Payer: Humana Commercial |
$106.91
|
| Rate for Payer: Humana KY Medicaid |
$43.26
|
| Rate for Payer: Kentucky WC Medicaid |
$43.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.69
|
| Rate for Payer: Ohio Health Group HMO |
$94.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.99
|
| Rate for Payer: PHCS Commercial |
$120.75
|
| Rate for Payer: United Healthcare All Payer |
$110.69
|
|
|
METHERGINE(METHYLERG .2MG/1TAB
|
Facility
|
IP
|
$125.78
|
|
|
Service Code
|
NDC 54063905
|
| Hospital Charge Code |
25000971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$120.75 |
| Rate for Payer: Aetna Commercial |
$96.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.11
|
| Rate for Payer: Cash Price |
$62.89
|
| Rate for Payer: Cigna Commercial |
$104.40
|
| Rate for Payer: First Health Commercial |
$119.49
|
| Rate for Payer: Humana Commercial |
$106.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.69
|
| Rate for Payer: Ohio Health Group HMO |
$94.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.99
|
| Rate for Payer: PHCS Commercial |
$120.75
|
| Rate for Payer: United Healthcare All Payer |
$110.69
|
|
|
METHERGINE(METHYLERGO .2MG/1ML
|
Facility
|
IP
|
$126.76
|
|
|
Service Code
|
HCPCS J2210
|
| Hospital Charge Code |
25002229
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$121.69 |
| Rate for Payer: Aetna Commercial |
$97.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.87
|
| Rate for Payer: Cash Price |
$63.38
|
| Rate for Payer: Cigna Commercial |
$105.21
|
| Rate for Payer: First Health Commercial |
$120.42
|
| Rate for Payer: Humana Commercial |
$107.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.55
|
| Rate for Payer: Ohio Health Group HMO |
$95.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.30
|
| Rate for Payer: PHCS Commercial |
$121.69
|
| Rate for Payer: United Healthcare All Payer |
$111.55
|
|
|
METHERGINE(METHYLERGO .2MG/1ML
|
Facility
|
OP
|
$126.76
|
|
|
Service Code
|
HCPCS J2210
|
| Hospital Charge Code |
25002229
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$121.69 |
| Rate for Payer: Aetna Commercial |
$97.61
|
| Rate for Payer: Anthem Medicaid |
$43.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.87
|
| Rate for Payer: Cash Price |
$63.38
|
| Rate for Payer: Cigna Commercial |
$105.21
|
| Rate for Payer: First Health Commercial |
$120.42
|
| Rate for Payer: Humana Commercial |
$107.75
|
| Rate for Payer: Humana KY Medicaid |
$43.59
|
| Rate for Payer: Kentucky WC Medicaid |
$44.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.55
|
| Rate for Payer: Ohio Health Group HMO |
$95.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.30
|
| Rate for Payer: PHCS Commercial |
$121.69
|
| Rate for Payer: United Healthcare All Payer |
$111.55
|
|
|
METHOTREXATE 2.5 MG 2.5MG/1TAB
|
Facility
|
IP
|
$9.86
|
|
|
Service Code
|
HCPCS J8610
|
| Hospital Charge Code |
25002540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.47 |
| Rate for Payer: Aetna Commercial |
$7.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.69
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna Commercial |
$8.18
|
| Rate for Payer: First Health Commercial |
$9.37
|
| Rate for Payer: Humana Commercial |
$8.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.68
|
| Rate for Payer: Ohio Health Group HMO |
$7.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$9.47
|
| Rate for Payer: United Healthcare All Payer |
$8.68
|
|
|
METHOTREXATE 2.5 MG 2.5MG/1TAB
|
Facility
|
OP
|
$9.86
|
|
|
Service Code
|
HCPCS J8610
|
| Hospital Charge Code |
25002540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.47 |
| Rate for Payer: Aetna Commercial |
$7.59
|
| Rate for Payer: Anthem Medicaid |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.69
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna Commercial |
$8.18
|
| Rate for Payer: First Health Commercial |
$9.37
|
| Rate for Payer: Humana Commercial |
$8.38
|
| Rate for Payer: Humana KY Medicaid |
$3.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.68
|
| Rate for Payer: Ohio Health Group HMO |
$7.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$9.47
|
| Rate for Payer: United Healthcare All Payer |
$8.68
|
|
|
METHOTREXATE 50MG (50MG SDV)
|
Facility
|
IP
|
$18.31
|
|
|
Service Code
|
HCPCS J9260
|
| Hospital Charge Code |
25002645
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$14.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$9.15
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: First Health Commercial |
$17.39
|
| Rate for Payer: Humana Commercial |
$15.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.11
|
| Rate for Payer: Ohio Health Group HMO |
$13.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.68
|
| Rate for Payer: PHCS Commercial |
$17.58
|
| Rate for Payer: United Healthcare All Payer |
$16.11
|
|
|
METHOTREXATE 50MG (50MG SDV)
|
Facility
|
OP
|
$18.31
|
|
|
Service Code
|
HCPCS J9260
|
| Hospital Charge Code |
25002645
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Aetna Commercial |
$14.10
|
| Rate for Payer: Anthem Medicaid |
$6.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$9.15
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: First Health Commercial |
$17.39
|
| Rate for Payer: Humana Commercial |
$15.56
|
| Rate for Payer: Humana KY Medicaid |
$6.30
|
| Rate for Payer: Kentucky WC Medicaid |
$6.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.11
|
| Rate for Payer: Ohio Health Group HMO |
$13.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.68
|
| Rate for Payer: PHCS Commercial |
$17.58
|
| Rate for Payer: United Healthcare All Payer |
$16.11
|
|
|
METHOTREXATE PF 250MG 10ML VL
|
Facility
|
OP
|
$183.07
|
|
|
Service Code
|
HCPCS J9260
|
| Hospital Charge Code |
25002647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$175.75 |
| Rate for Payer: Aetna Commercial |
$140.96
|
| Rate for Payer: Anthem Medicaid |
$62.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.79
|
| Rate for Payer: Cash Price |
$91.53
|
| Rate for Payer: Cigna Commercial |
$151.95
|
| Rate for Payer: First Health Commercial |
$173.92
|
| Rate for Payer: Humana Commercial |
$155.61
|
| Rate for Payer: Humana KY Medicaid |
$62.96
|
| Rate for Payer: Kentucky WC Medicaid |
$63.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.10
|
| Rate for Payer: Ohio Health Group HMO |
$137.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.75
|
| Rate for Payer: PHCS Commercial |
$175.75
|
| Rate for Payer: United Healthcare All Payer |
$161.10
|
|
|
METHOTREXATE PF 250MG 10ML VL
|
Facility
|
IP
|
$183.07
|
|
|
Service Code
|
HCPCS J9260
|
| Hospital Charge Code |
25002647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$175.75 |
| Rate for Payer: Aetna Commercial |
$140.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.79
|
| Rate for Payer: Cash Price |
$91.53
|
| Rate for Payer: Cigna Commercial |
$151.95
|
| Rate for Payer: First Health Commercial |
$173.92
|
| Rate for Payer: Humana Commercial |
$155.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.10
|
| Rate for Payer: Ohio Health Group HMO |
$137.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.75
|
| Rate for Payer: PHCS Commercial |
$175.75
|
| Rate for Payer: United Healthcare All Payer |
$161.10
|
|
