|
MIOSTAT (CARBACHOL) 0.01 1.5ML
|
Facility
|
IP
|
$200.68
|
|
|
Service Code
|
NDC 65002315
|
| Hospital Charge Code |
25000993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.09 |
| Max. Negotiated Rate |
$192.65 |
| Rate for Payer: Aetna Commercial |
$154.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.53
|
| Rate for Payer: Cash Price |
$100.34
|
| Rate for Payer: Cigna Commercial |
$166.56
|
| Rate for Payer: First Health Commercial |
$190.65
|
| Rate for Payer: Humana Commercial |
$170.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.60
|
| Rate for Payer: Ohio Health Group HMO |
$150.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.21
|
| Rate for Payer: PHCS Commercial |
$192.65
|
| Rate for Payer: United Healthcare All Payer |
$176.60
|
|
|
MIRACLE BROS 12 PTCA GW 300CM
|
Facility
|
OP
|
$1,770.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$230.10 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$1,362.90
|
| Rate for Payer: Anthem Medicaid |
$608.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,380.60
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$1,469.10
|
| Rate for Payer: First Health Commercial |
$1,681.50
|
| Rate for Payer: Humana Commercial |
$1,504.50
|
| Rate for Payer: Humana KY Medicaid |
$608.70
|
| Rate for Payer: Kentucky WC Medicaid |
$614.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$620.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,557.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,327.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.70
|
| Rate for Payer: PHCS Commercial |
$1,699.20
|
| Rate for Payer: United Healthcare All Payer |
$1,557.60
|
|
|
MIRACLE BROS 12 PTCA GW 300CM
|
Facility
|
IP
|
$1,770.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$230.10 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$1,362.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,380.60
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$1,469.10
|
| Rate for Payer: First Health Commercial |
$1,681.50
|
| Rate for Payer: Humana Commercial |
$1,504.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,557.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,327.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.70
|
| Rate for Payer: PHCS Commercial |
$1,699.20
|
| Rate for Payer: United Healthcare All Payer |
$1,557.60
|
|
|
MIRACLE BROS 6 PTCA GW 300CM
|
Facility
|
OP
|
$1,770.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$230.10 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$1,362.90
|
| Rate for Payer: Anthem Medicaid |
$608.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,380.60
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$1,469.10
|
| Rate for Payer: First Health Commercial |
$1,681.50
|
| Rate for Payer: Humana Commercial |
$1,504.50
|
| Rate for Payer: Humana KY Medicaid |
$608.70
|
| Rate for Payer: Kentucky WC Medicaid |
$614.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$620.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,557.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,327.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.70
|
| Rate for Payer: PHCS Commercial |
$1,699.20
|
| Rate for Payer: United Healthcare All Payer |
$1,557.60
|
|
|
MIRACLE BROS 6 PTCA GW 300CM
|
Facility
|
IP
|
$1,770.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$230.10 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$1,362.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,380.60
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$1,469.10
|
| Rate for Payer: First Health Commercial |
$1,681.50
|
| Rate for Payer: Humana Commercial |
$1,504.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,557.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,327.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.70
|
| Rate for Payer: PHCS Commercial |
$1,699.20
|
| Rate for Payer: United Healthcare All Payer |
$1,557.60
|
|
|
MIRALAX EQUIV(238GM) POWDER
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 45802086802
|
| Hospital Charge Code |
25000996
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
MIRALAX EQUIV(238GM) POWDER
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 45802086802
|
| Hospital Charge Code |
25000996
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
MIRALAX (POLYETHIENE) 17 GRAM
|
Facility
|
OP
|
$9.13
|
|
|
Service Code
|
NDC 11523726808
|
| Hospital Charge Code |
25000994
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.03
|
| Rate for Payer: Anthem Medicaid |
$3.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Cash Price |
$4.57
|
| Rate for Payer: Cigna Commercial |
$7.58
|
| Rate for Payer: First Health Commercial |
$8.67
|
| Rate for Payer: Humana Commercial |
$7.76
|
| Rate for Payer: Humana KY Medicaid |
$3.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.83
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
MIRALAX (POLYETHIENE) 17 GRAM
|
Facility
|
IP
|
$9.13
|
|
|
Service Code
|
NDC 11523726808
|
| Hospital Charge Code |
25000994
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Humana Commercial |
$7.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.83
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
| Rate for Payer: Aetna Commercial |
$7.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Cash Price |
$4.57
|
| Rate for Payer: Cigna Commercial |
$7.58
|
| Rate for Payer: First Health Commercial |
$8.67
|
|
|
MIRAPEX 0.125 MG TABLET
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 13668009190
|
| Hospital Charge Code |
25000997
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
MIRAPEX 0.125 MG TABLET
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 13668009190
|
| Hospital Charge Code |
25000997
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
MIRAPEX 0.25 MG TABLET
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 60687057001
|
| Hospital Charge Code |
25000998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
MIRAPEX 0.25 MG TABLET
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 60687057001
|
| Hospital Charge Code |
25000998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
MIRAPEX 0.5 MG TABLET
|
Facility
|
OP
|
$5.03
|
|
|
Service Code
|
NDC 60687058121
|
| Hospital Charge Code |
25000999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.43
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.56
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.78
|
|
|
MIRAPEX 0.5 MG TABLET
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
NDC 60687058121
|
| Hospital Charge Code |
25000999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.78
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.43
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.56
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
63600071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
636T0071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
63600071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
636T0071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
| Rate for Payer: Aetna Commercial |
$1,347.50
|
|
|
MIRENA 20 MCG/24HR IUD
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
63600071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$612.50 |
| Max. Negotiated Rate |
$1,750.00 |
| Rate for Payer: Aetna Commercial |
$1,366.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,750.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,445.41
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,225.00
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
|
|
MIRENA IUD
|
Facility
|
OP
|
$3,295.96
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$428.47 |
| Max. Negotiated Rate |
$3,164.12 |
| Rate for Payer: Aetna Commercial |
$2,537.89
|
| Rate for Payer: Anthem Medicaid |
$1,133.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,570.85
|
| Rate for Payer: Cash Price |
$1,647.98
|
| Rate for Payer: Cigna Commercial |
$2,735.65
|
| Rate for Payer: First Health Commercial |
$3,131.16
|
| Rate for Payer: Humana Commercial |
$2,801.57
|
| Rate for Payer: Humana KY Medicaid |
$1,133.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,145.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,702.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,432.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$988.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,156.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,900.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,471.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$659.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,021.75
|
| Rate for Payer: PHCS Commercial |
$3,164.12
|
| Rate for Payer: United Healthcare All Payer |
$2,900.44
|
|
|
MIRENA IUD
|
Facility
|
IP
|
$3,295.96
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$428.47 |
| Max. Negotiated Rate |
$3,164.12 |
| Rate for Payer: Aetna Commercial |
$2,537.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,570.85
|
| Rate for Payer: Cash Price |
$1,647.98
|
| Rate for Payer: Cigna Commercial |
$2,735.65
|
| Rate for Payer: First Health Commercial |
$3,131.16
|
| Rate for Payer: Humana Commercial |
$2,801.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,702.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,432.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$988.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,900.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,471.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$659.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,021.75
|
| Rate for Payer: PHCS Commercial |
$3,164.12
|
| Rate for Payer: United Healthcare All Payer |
$2,900.44
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$15,385.47
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$10,440.14 |
| Max. Negotiated Rate |
$15,385.47 |
| Rate for Payer: Anthem Medicaid |
$10,440.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,989.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,385.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,835.99
|
| Rate for Payer: Humana KY Medicaid |
$10,440.14
|
| Rate for Payer: Humana Medicare Advantage |
$10,989.62
|
| Rate for Payer: Kentucky WC Medicaid |
$10,544.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,187.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,648.94
|
|
