|
MONOFERRIC 10mg (1,000mg)
|
Facility
|
IP
|
$18,402.69
|
|
|
Service Code
|
HCPCS J1437
|
| Hospital Charge Code |
25004131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,392.35 |
| Max. Negotiated Rate |
$17,666.58 |
| Rate for Payer: Aetna Commercial |
$14,170.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,354.10
|
| Rate for Payer: Cash Price |
$9,201.34
|
| Rate for Payer: Cigna Commercial |
$15,274.23
|
| Rate for Payer: First Health Commercial |
$17,482.56
|
| Rate for Payer: Humana Commercial |
$15,642.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,090.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,581.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,520.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,194.37
|
| Rate for Payer: Ohio Health Group HMO |
$13,802.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,680.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,392.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,704.83
|
| Rate for Payer: PHCS Commercial |
$17,666.58
|
| Rate for Payer: United Healthcare All Payer |
$16,194.37
|
|
|
MONOPRIL 40MG EQUIVALENT TAB
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 69097085805
|
| Hospital Charge Code |
25003214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MONOPRIL 40MG EQUIVALENT TAB
|
Facility
|
IP
|
$4.54
|
|
|
Service Code
|
NDC 69097085805
|
| Hospital Charge Code |
25003214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MONOPRIL (FOSINOPRIL 10MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 43547038609
|
| Hospital Charge Code |
25001010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
MONOPRIL (FOSINOPRIL 10MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 43547038609
|
| Hospital Charge Code |
25001010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
MONO TEST
|
Professional
|
Both
|
$47.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
30001041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$8.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.00
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cigna Commercial |
$7.28
|
| Rate for Payer: Healthspan PPO |
$5.42
|
| Rate for Payer: Multiplan PHCS |
$28.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$32.90
|
| Rate for Payer: UHCCP Medicaid |
$16.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.11
|
|
|
MONO TEST
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
30001041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Aetna Commercial |
$36.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.74
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cigna Commercial |
$39.01
|
| Rate for Payer: First Health Commercial |
$44.65
|
| Rate for Payer: Humana Commercial |
$39.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$34.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$41.36
|
| Rate for Payer: Ohio Health Group HMO |
$35.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.57
|
| Rate for Payer: PHCS Commercial |
$45.12
|
| Rate for Payer: United Healthcare All Payer |
$41.36
|
|
|
MONO TEST
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
30001041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Aetna Commercial |
$36.19
|
| Rate for Payer: Anthem Medicaid |
$5.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.18
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cash Price |
$23.50
|
| Rate for Payer: Cigna Commercial |
$39.01
|
| Rate for Payer: First Health Commercial |
$44.65
|
| Rate for Payer: Humana Commercial |
$39.95
|
| Rate for Payer: Humana KY Medicaid |
$5.18
|
| Rate for Payer: Humana Medicare Advantage |
$5.18
|
| Rate for Payer: Kentucky WC Medicaid |
$5.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$34.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$41.36
|
| Rate for Payer: Ohio Health Group HMO |
$35.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.57
|
| Rate for Payer: PHCS Commercial |
$45.12
|
| Rate for Payer: United Healthcare All Payer |
$41.36
|
|
|
MONSEL 8ML
|
Facility
|
OP
|
$91.09
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$87.45 |
| Rate for Payer: Aetna Commercial |
$70.14
|
| Rate for Payer: Anthem Medicaid |
$31.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.05
|
| Rate for Payer: Cash Price |
$45.55
|
| Rate for Payer: Cigna Commercial |
$75.60
|
| Rate for Payer: First Health Commercial |
$86.54
|
| Rate for Payer: Humana Commercial |
$77.43
|
| Rate for Payer: Humana KY Medicaid |
$31.33
|
| Rate for Payer: Kentucky WC Medicaid |
$31.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.16
|
| Rate for Payer: Ohio Health Group HMO |
$68.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.24
|
| Rate for Payer: PHCS Commercial |
$87.45
|
| Rate for Payer: United Healthcare All Payer |
$80.16
|
|
|
MONSEL 8ML
|
Facility
|
IP
|
$91.09
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$87.45 |
| Rate for Payer: Aetna Commercial |
$70.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.05
|
| Rate for Payer: Cash Price |
$45.55
|
| Rate for Payer: Cigna Commercial |
$75.60
|
| Rate for Payer: First Health Commercial |
$86.54
|
| Rate for Payer: Humana Commercial |
$77.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.16
|
| Rate for Payer: Ohio Health Group HMO |
$68.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.24
|
| Rate for Payer: PHCS Commercial |
$87.45
|
| Rate for Payer: United Healthcare All Payer |
$80.16
|
|
|
MONSEL FERRIC SUBSULF SOL(8ML)
|
Facility
|
OP
|
$90.65
|
|
|
Service Code
|
NDC 59365606500
|
| Hospital Charge Code |
25003217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$87.02 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: Anthem Medicaid |
$31.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.71
|
| Rate for Payer: Cash Price |
$45.33
|
| Rate for Payer: Cigna Commercial |
$75.24
|
| Rate for Payer: First Health Commercial |
$86.12
|
| Rate for Payer: Humana Commercial |
$77.05
|
| Rate for Payer: Humana KY Medicaid |
$31.17
|
| Rate for Payer: Kentucky WC Medicaid |
$31.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.77
|
| Rate for Payer: Ohio Health Group HMO |
$67.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.10
|
| Rate for Payer: PHCS Commercial |
$87.02
|
| Rate for Payer: United Healthcare All Payer |
$79.77
|
|
|
MONSEL FERRIC SUBSULF SOL(8ML)
|
Facility
|
IP
|
$90.65
|
|
|
Service Code
|
NDC 59365606500
|
| Hospital Charge Code |
25003217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$87.02 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.71
|
| Rate for Payer: Cash Price |
$45.33
|
| Rate for Payer: Cigna Commercial |
$75.24
|
| Rate for Payer: First Health Commercial |
$86.12
|
| Rate for Payer: Humana Commercial |
$77.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.77
|
| Rate for Payer: Ohio Health Group HMO |
$67.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.10
|
| Rate for Payer: PHCS Commercial |
$87.02
|
| Rate for Payer: United Healthcare All Payer |
$79.77
|
|
|
MONSELS[FERRIC SULF]SOLU 20ML
|
Facility
|
OP
|
$78.88
|
|
|
Service Code
|
NDC 38779128405
|
| Hospital Charge Code |
25003218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$75.72 |
| Rate for Payer: Aetna Commercial |
$60.74
|
| Rate for Payer: Anthem Medicaid |
$27.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.53
|
| Rate for Payer: Cash Price |
$39.44
|
| Rate for Payer: Cigna Commercial |
$65.47
|
| Rate for Payer: First Health Commercial |
$74.94
|
| Rate for Payer: Humana Commercial |
$67.05
|
| Rate for Payer: Humana KY Medicaid |
$27.13
|
| Rate for Payer: Kentucky WC Medicaid |
$27.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.41
|
| Rate for Payer: Ohio Health Group HMO |
$59.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.45
|
| Rate for Payer: PHCS Commercial |
$75.72
|
| Rate for Payer: United Healthcare All Payer |
$69.41
|
|
|
MONSELS[FERRIC SULF]SOLU 20ML
|
Facility
|
IP
|
$78.88
|
|
|
Service Code
|
NDC 38779128405
|
| Hospital Charge Code |
25003218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$75.72 |
| Rate for Payer: Aetna Commercial |
$60.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.53
|
| Rate for Payer: Cash Price |
$39.44
|
| Rate for Payer: Cigna Commercial |
$65.47
|
| Rate for Payer: First Health Commercial |
$74.94
|
| Rate for Payer: Humana Commercial |
$67.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.41
|
| Rate for Payer: Ohio Health Group HMO |
$59.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.45
|
| Rate for Payer: PHCS Commercial |
$75.72
|
| Rate for Payer: United Healthcare All Payer |
$69.41
|
|
|
MONTAGE PATIENT TRIAL KIT
|
Facility
|
OP
|
$1,162.35
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$151.11 |
| Max. Negotiated Rate |
$1,115.86 |
| Rate for Payer: Aetna Commercial |
$895.01
|
| Rate for Payer: Anthem Medicaid |
$399.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.63
|
| Rate for Payer: Cash Price |
$581.18
|
| Rate for Payer: Cigna Commercial |
$964.75
|
| Rate for Payer: First Health Commercial |
$1,104.23
|
| Rate for Payer: Humana Commercial |
$988.00
|
| Rate for Payer: Humana KY Medicaid |
$399.73
|
| Rate for Payer: Kentucky WC Medicaid |
$403.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$953.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$407.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.87
|
| Rate for Payer: Ohio Health Group HMO |
$871.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.33
|
| Rate for Payer: PHCS Commercial |
$1,115.86
|
| Rate for Payer: United Healthcare All Payer |
$1,022.87
|
|
|
MONTAGE PATIENT TRIAL KIT
|
Facility
|
IP
|
$1,162.35
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$151.11 |
| Max. Negotiated Rate |
$1,115.86 |
| Rate for Payer: Aetna Commercial |
$895.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.63
|
| Rate for Payer: Cash Price |
$581.18
|
| Rate for Payer: Cigna Commercial |
$964.75
|
| Rate for Payer: First Health Commercial |
$1,104.23
|
| Rate for Payer: Humana Commercial |
$988.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$953.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.87
|
| Rate for Payer: Ohio Health Group HMO |
$871.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.33
|
| Rate for Payer: PHCS Commercial |
$1,115.86
|
| Rate for Payer: United Healthcare All Payer |
$1,022.87
|
|
|
MONTAGE PUL GEN FULL BDY MRI S
|
Facility
|
OP
|
$88,180.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,463.40 |
| Max. Negotiated Rate |
$84,652.80 |
| Rate for Payer: Aetna Commercial |
$67,898.60
|
| Rate for Payer: Anthem Medicaid |
$30,325.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68,780.40
|
| Rate for Payer: Cash Price |
$44,090.00
|
| Rate for Payer: Cigna Commercial |
$73,189.40
|
| Rate for Payer: First Health Commercial |
$83,771.00
|
| Rate for Payer: Humana Commercial |
$74,953.00
|
| Rate for Payer: Humana KY Medicaid |
$30,325.10
|
| Rate for Payer: Kentucky WC Medicaid |
$30,633.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72,307.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65,076.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26,454.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$30,933.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$77,598.40
|
| Rate for Payer: Ohio Health Group HMO |
$66,135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,463.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,335.80
|
| Rate for Payer: PHCS Commercial |
$84,652.80
|
| Rate for Payer: United Healthcare All Payer |
$77,598.40
|
|
|
MONTAGE PUL GEN FULL BDY MRI S
|
Facility
|
IP
|
$88,180.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,463.40 |
| Max. Negotiated Rate |
$84,652.80 |
| Rate for Payer: Aetna Commercial |
$67,898.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68,780.40
|
| Rate for Payer: Cash Price |
$44,090.00
|
| Rate for Payer: Cigna Commercial |
$73,189.40
|
| Rate for Payer: First Health Commercial |
$83,771.00
|
| Rate for Payer: Humana Commercial |
$74,953.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72,307.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65,076.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26,454.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$77,598.40
|
| Rate for Payer: Ohio Health Group HMO |
$66,135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,463.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,335.80
|
| Rate for Payer: PHCS Commercial |
$84,652.80
|
| Rate for Payer: United Healthcare All Payer |
$77,598.40
|
|
|
MONTR CARDI CONFIRM ICM DM2100
|
Facility
|
OP
|
$15,000.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$14,400.00 |
| Rate for Payer: Aetna Commercial |
$11,550.00
|
| Rate for Payer: Anthem Medicaid |
$5,158.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,700.00
|
| Rate for Payer: Cash Price |
$7,500.00
|
| Rate for Payer: Cigna Commercial |
$12,450.00
|
| Rate for Payer: First Health Commercial |
$14,250.00
|
| Rate for Payer: Humana Commercial |
$12,750.00
|
| Rate for Payer: Humana KY Medicaid |
$5,158.50
|
| Rate for Payer: Kentucky WC Medicaid |
$5,211.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,300.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,070.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,262.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,650.00
|
| Rate for Payer: PHCS Commercial |
$14,400.00
|
| Rate for Payer: United Healthcare All Payer |
$13,200.00
|
|
|
MONTR CARDI CONFIRM ICM DM2100
|
Facility
|
IP
|
$15,000.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$14,400.00 |
| Rate for Payer: Aetna Commercial |
$11,550.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,700.00
|
| Rate for Payer: Cash Price |
$7,500.00
|
| Rate for Payer: Cigna Commercial |
$12,450.00
|
| Rate for Payer: First Health Commercial |
$14,250.00
|
| Rate for Payer: Humana Commercial |
$12,750.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,300.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,070.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,650.00
|
| Rate for Payer: PHCS Commercial |
$14,400.00
|
| Rate for Payer: United Healthcare All Payer |
$13,200.00
|
|
|
MONUROL 3 GRAM PACKET
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
25003219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem Medicaid |
$45.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.96
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Humana KY Medicaid |
$45.39
|
| Rate for Payer: Kentucky WC Medicaid |
$45.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
MONUROL 3 GRAM PACKET
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
25003219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.96
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
MORPHINE 0.4MG/ML ORSOL(0.5ML)
|
Facility
|
IP
|
$60.19
|
|
|
Service Code
|
NDC 27808008202
|
| Hospital Charge Code |
25003222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.78 |
| Rate for Payer: Aetna Commercial |
$46.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.95
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.96
|
| Rate for Payer: First Health Commercial |
$57.18
|
| Rate for Payer: Humana Commercial |
$51.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.97
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.66
|
| Rate for Payer: PHCS Commercial |
$57.78
|
| Rate for Payer: United Healthcare All Payer |
$52.97
|
|
|
MORPHINE 0.4MG/ML ORSOL(0.5ML)
|
Facility
|
OP
|
$60.19
|
|
|
Service Code
|
NDC 27808008202
|
| Hospital Charge Code |
25003222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.78 |
| Rate for Payer: Anthem Medicaid |
$20.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.95
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.96
|
| Rate for Payer: First Health Commercial |
$57.18
|
| Rate for Payer: Humana Commercial |
$51.16
|
| Rate for Payer: Humana KY Medicaid |
$20.70
|
| Rate for Payer: Kentucky WC Medicaid |
$20.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.97
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.66
|
| Rate for Payer: PHCS Commercial |
$57.78
|
| Rate for Payer: United Healthcare All Payer |
$52.97
|
| Rate for Payer: Aetna Commercial |
$46.35
|
|
|
MORPHINE 10mg PF Cartridge
|
Facility
|
OP
|
$77.31
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
25004414
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$74.22 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.30
|
| Rate for Payer: Cash Price |
$38.66
|
| Rate for Payer: Cigna Commercial |
$64.17
|
| Rate for Payer: First Health Commercial |
$73.44
|
| Rate for Payer: Humana Commercial |
$65.71
|
| Rate for Payer: Humana KY Medicaid |
$26.59
|
| Rate for Payer: Kentucky WC Medicaid |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.03
|
| Rate for Payer: Ohio Health Group HMO |
$57.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.97
|
| Rate for Payer: PHCS Commercial |
$74.22
|
| Rate for Payer: United Healthcare All Payer |
$68.03
|
| Rate for Payer: Aetna Commercial |
$59.53
|
| Rate for Payer: Anthem Medicaid |
$26.59
|
|
