|
MOTILITY STUDY
|
Professional
|
Both
|
$837.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
32000135
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$837.00 |
| Rate for Payer: Aetna Commercial |
$151.82
|
| Rate for Payer: Anthem Medicaid |
$91.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$837.00
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Healthspan PPO |
$142.26
|
| Rate for Payer: Humana Medicaid |
$91.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$92.85
|
| Rate for Payer: Molina Healthcare Passport |
$91.03
|
| Rate for Payer: Multiplan PHCS |
$502.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$585.90
|
| Rate for Payer: UHCCP Medicaid |
$292.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$91.94
|
|
|
MOTILITY STUDY
|
Facility
|
IP
|
$837.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
32000135
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.81 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$644.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.86
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cigna Commercial |
$694.71
|
| Rate for Payer: First Health Commercial |
$795.15
|
| Rate for Payer: Humana Commercial |
$711.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$686.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$617.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$736.56
|
| Rate for Payer: Ohio Health Group HMO |
$627.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.47
|
| Rate for Payer: PHCS Commercial |
$803.52
|
| Rate for Payer: United Healthcare All Payer |
$736.56
|
|
|
MOTILITY STUDY(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
320P0135
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$151.82 |
| Rate for Payer: Aetna Commercial |
$151.82
|
| Rate for Payer: Anthem Medicaid |
$91.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Healthspan PPO |
$142.26
|
| Rate for Payer: Humana Medicaid |
$91.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$92.85
|
| Rate for Payer: Molina Healthcare Passport |
$91.03
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$91.94
|
|
|
MOTILITY STUDY(T
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
320T0135
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
MOTILITY STUDY(T
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS 74250
|
| Hospital Charge Code |
320T0135
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem Medicaid |
$253.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Humana KY Medicaid |
$253.45
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$256.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
MOTION FLUOROSCOPY/SWALLOW
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
HCPCS 92611
|
| Hospital Charge Code |
44000014
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$65.39 |
| Max. Negotiated Rate |
$482.88 |
| Rate for Payer: Aetna Commercial |
$387.31
|
| Rate for Payer: Anthem Medicaid |
$172.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$392.34
|
| Rate for Payer: Cash Price |
$251.50
|
| Rate for Payer: Cigna Commercial |
$417.49
|
| Rate for Payer: First Health Commercial |
$477.85
|
| Rate for Payer: Humana Commercial |
$427.55
|
| Rate for Payer: Humana KY Medicaid |
$172.98
|
| Rate for Payer: Kentucky WC Medicaid |
$174.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$412.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$176.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$442.64
|
| Rate for Payer: Ohio Health Group HMO |
$377.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.93
|
| Rate for Payer: PHCS Commercial |
$482.88
|
| Rate for Payer: United Healthcare All Payer |
$442.64
|
|
|
MOTION FLUOROSCOPY/SWALLOW
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
HCPCS 92611
|
| Hospital Charge Code |
44000014
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$65.39 |
| Max. Negotiated Rate |
$482.88 |
| Rate for Payer: Aetna Commercial |
$387.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$392.34
|
| Rate for Payer: Cash Price |
$251.50
|
| Rate for Payer: Cigna Commercial |
$417.49
|
| Rate for Payer: First Health Commercial |
$477.85
|
| Rate for Payer: Humana Commercial |
$427.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$412.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$442.64
|
| Rate for Payer: Ohio Health Group HMO |
$377.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.93
|
| Rate for Payer: PHCS Commercial |
$482.88
|
| Rate for Payer: United Healthcare All Payer |
$442.64
|
|
|
MOTRIN 200MG TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 904791461
|
| Hospital Charge Code |
25001013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
| Rate for Payer: Aetna Commercial |
$3.29
|
|
|
MOTRIN 200MG TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904791461
|
| Hospital Charge Code |
25001013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
MOTRIN (IBUPROFEN) 400MG/1TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 904585361
|
| Hospital Charge Code |
25001011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
MOTRIN (IBUPROFEN) 400MG/1TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904585361
|
| Hospital Charge Code |
25001011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
MOTRIN (IBUPROFEN) 600MG/1TAB
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 904585461
|
| Hospital Charge Code |
25001012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
MOTRIN (IBUPROFEN) 600MG/1TAB
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 904585461
|
| Hospital Charge Code |
25001012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
MOUTH PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$17,602.28
|
|
|
Service Code
|
MSDRG 137
|
| Min. Negotiated Rate |
$11,944.41 |
| Max. Negotiated Rate |
$17,602.28 |
| Rate for Payer: Anthem Medicaid |
$11,944.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12,573.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17,602.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$16,973.63
|
| Rate for Payer: Humana KY Medicaid |
$11,944.41
|
| Rate for Payer: Humana Medicare Advantage |
$12,573.06
|
| Rate for Payer: Kentucky WC Medicaid |
$12,063.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,087.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,183.30
|
|
|
MOUTH PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$10,127.14
|
|
|
Service Code
|
MSDRG 138
|
| Min. Negotiated Rate |
$6,871.99 |
| Max. Negotiated Rate |
$10,127.14 |
| Rate for Payer: Anthem Medicaid |
$6,871.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,233.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,127.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,765.45
|
| Rate for Payer: Humana KY Medicaid |
$6,871.99
|
| Rate for Payer: Humana Medicare Advantage |
$7,233.67
|
| Rate for Payer: Kentucky WC Medicaid |
$6,940.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,009.43
|
|
|
MOXIFLOXACIN 150MCG/0.1ML (1ML
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 68180042201
|
| Hospital Charge Code |
25003233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: Anthem Medicaid |
$38.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.36
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$92.96
|
| Rate for Payer: First Health Commercial |
$106.40
|
| Rate for Payer: Humana Commercial |
$95.20
|
| Rate for Payer: Humana KY Medicaid |
$38.52
|
| Rate for Payer: Kentucky WC Medicaid |
$38.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.56
|
| Rate for Payer: Ohio Health Group HMO |
$84.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.72
|
| Rate for Payer: PHCS Commercial |
$107.52
|
| Rate for Payer: United Healthcare All Payer |
$98.56
|
|
|
MOXIFLOXACIN 150MCG/0.1ML (1ML
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 68180042201
|
| Hospital Charge Code |
25003233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.36
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$92.96
|
| Rate for Payer: First Health Commercial |
$106.40
|
| Rate for Payer: Humana Commercial |
$95.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.56
|
| Rate for Payer: Ohio Health Group HMO |
$84.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.72
|
| Rate for Payer: PHCS Commercial |
$107.52
|
| Rate for Payer: United Healthcare All Payer |
$98.56
|
|
|
MOXIFLOXACIN HCL 400MG TAB
|
Facility
|
OP
|
$23.75
|
|
|
Service Code
|
NDC 50268057613
|
| Hospital Charge Code |
25003857
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Aetna Commercial |
$18.29
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.52
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cigna Commercial |
$19.71
|
| Rate for Payer: First Health Commercial |
$22.56
|
| Rate for Payer: Humana Commercial |
$20.19
|
| Rate for Payer: Humana KY Medicaid |
$8.17
|
| Rate for Payer: Kentucky WC Medicaid |
$8.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.90
|
| Rate for Payer: Ohio Health Group HMO |
$17.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.36
|
| Rate for Payer: PHCS Commercial |
$22.80
|
| Rate for Payer: United Healthcare All Payer |
$20.90
|
|
|
MOXIFLOXACIN HCL 400MG TAB
|
Facility
|
IP
|
$23.75
|
|
|
Service Code
|
NDC 50268057613
|
| Hospital Charge Code |
25003857
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.52
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cigna Commercial |
$19.71
|
| Rate for Payer: First Health Commercial |
$22.56
|
| Rate for Payer: Humana Commercial |
$20.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.90
|
| Rate for Payer: Ohio Health Group HMO |
$17.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.36
|
| Rate for Payer: PHCS Commercial |
$22.80
|
| Rate for Payer: United Healthcare All Payer |
$20.90
|
| Rate for Payer: Aetna Commercial |
$18.29
|
|
|
MPA 1 115CM
|
Facility
|
IP
|
$1,879.20
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.30 |
| Max. Negotiated Rate |
$1,804.03 |
| Rate for Payer: Aetna Commercial |
$1,446.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,465.78
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cigna Commercial |
$1,559.74
|
| Rate for Payer: First Health Commercial |
$1,785.24
|
| Rate for Payer: Humana Commercial |
$1,597.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,540.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,386.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,653.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,409.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$582.55
|
| Rate for Payer: PHCS Commercial |
$1,804.03
|
| Rate for Payer: United Healthcare All Payer |
$1,653.70
|
|
|
MPA 1 115CM
|
Facility
|
OP
|
$1,879.20
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.30 |
| Max. Negotiated Rate |
$1,804.03 |
| Rate for Payer: Aetna Commercial |
$1,446.98
|
| Rate for Payer: Anthem Medicaid |
$646.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,465.78
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cigna Commercial |
$1,559.74
|
| Rate for Payer: First Health Commercial |
$1,785.24
|
| Rate for Payer: Humana Commercial |
$1,597.32
|
| Rate for Payer: Humana KY Medicaid |
$646.26
|
| Rate for Payer: Kentucky WC Medicaid |
$652.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,540.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,386.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$659.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,653.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,409.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$582.55
|
| Rate for Payer: PHCS Commercial |
$1,804.03
|
| Rate for Payer: United Healthcare All Payer |
$1,653.70
|
|
|
MPA-1 5FR
|
Facility
|
OP
|
$154.30
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.06 |
| Max. Negotiated Rate |
$148.13 |
| Rate for Payer: Aetna Commercial |
$118.81
|
| Rate for Payer: Anthem Medicaid |
$53.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.35
|
| Rate for Payer: Cash Price |
$77.15
|
| Rate for Payer: Cigna Commercial |
$128.07
|
| Rate for Payer: First Health Commercial |
$146.58
|
| Rate for Payer: Humana Commercial |
$131.16
|
| Rate for Payer: Humana KY Medicaid |
$53.06
|
| Rate for Payer: Kentucky WC Medicaid |
$53.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$126.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$113.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$135.78
|
| Rate for Payer: Ohio Health Group HMO |
$115.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.83
|
| Rate for Payer: PHCS Commercial |
$148.13
|
| Rate for Payer: United Healthcare All Payer |
$135.78
|
|
|
MPA-1 5FR
|
Facility
|
IP
|
$154.30
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.06 |
| Max. Negotiated Rate |
$148.13 |
| Rate for Payer: Aetna Commercial |
$118.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.35
|
| Rate for Payer: Cash Price |
$77.15
|
| Rate for Payer: Cigna Commercial |
$128.07
|
| Rate for Payer: First Health Commercial |
$146.58
|
| Rate for Payer: Humana Commercial |
$131.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$126.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$113.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$135.78
|
| Rate for Payer: Ohio Health Group HMO |
$115.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.83
|
| Rate for Payer: PHCS Commercial |
$148.13
|
| Rate for Payer: United Healthcare All Payer |
$135.78
|
|
|
MPA 1 GUIDE 125CM
|
Facility
|
IP
|
$1,879.20
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.30 |
| Max. Negotiated Rate |
$1,804.03 |
| Rate for Payer: Aetna Commercial |
$1,446.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,465.78
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cigna Commercial |
$1,559.74
|
| Rate for Payer: First Health Commercial |
$1,785.24
|
| Rate for Payer: Humana Commercial |
$1,597.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,540.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,386.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,653.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,409.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$582.55
|
| Rate for Payer: PHCS Commercial |
$1,804.03
|
| Rate for Payer: United Healthcare All Payer |
$1,653.70
|
|
|
MPA 1 GUIDE 125CM
|
Facility
|
OP
|
$1,879.20
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.30 |
| Max. Negotiated Rate |
$1,804.03 |
| Rate for Payer: Aetna Commercial |
$1,446.98
|
| Rate for Payer: Anthem Medicaid |
$646.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,465.78
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cigna Commercial |
$1,559.74
|
| Rate for Payer: First Health Commercial |
$1,785.24
|
| Rate for Payer: Humana Commercial |
$1,597.32
|
| Rate for Payer: Humana KY Medicaid |
$646.26
|
| Rate for Payer: Kentucky WC Medicaid |
$652.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,540.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,386.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$659.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,653.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,409.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$582.55
|
| Rate for Payer: PHCS Commercial |
$1,804.03
|
| Rate for Payer: United Healthcare All Payer |
$1,653.70
|
|
