|
MIACALCIN (CALCI/S 200IU/1SPRA
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 60505082306
|
| Hospital Charge Code |
25000980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
MICAFUNGIN 1MG (100MG) SDV
|
Facility
|
IP
|
$577.60
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
25004550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.28 |
| Max. Negotiated Rate |
$554.50 |
| Rate for Payer: Aetna Commercial |
$444.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.53
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cigna Commercial |
$479.41
|
| Rate for Payer: First Health Commercial |
$548.72
|
| Rate for Payer: Humana Commercial |
$490.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$426.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$508.29
|
| Rate for Payer: Ohio Health Group HMO |
$433.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.54
|
| Rate for Payer: PHCS Commercial |
$554.50
|
| Rate for Payer: United Healthcare All Payer |
$508.29
|
|
|
MICAFUNGIN 1MG (100MG) SDV
|
Facility
|
OP
|
$577.60
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
25004550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.28 |
| Max. Negotiated Rate |
$554.50 |
| Rate for Payer: Aetna Commercial |
$444.75
|
| Rate for Payer: Anthem Medicaid |
$198.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.53
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cigna Commercial |
$479.41
|
| Rate for Payer: First Health Commercial |
$548.72
|
| Rate for Payer: Humana Commercial |
$490.96
|
| Rate for Payer: Humana KY Medicaid |
$198.64
|
| Rate for Payer: Kentucky WC Medicaid |
$200.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$426.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$202.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$508.29
|
| Rate for Payer: Ohio Health Group HMO |
$433.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.54
|
| Rate for Payer: PHCS Commercial |
$554.50
|
| Rate for Payer: United Healthcare All Payer |
$508.29
|
|
|
MICAFUNGIN 1MG(50MG) SDV
|
Facility
|
OP
|
$362.50
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
25004529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.75 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$279.12
|
| Rate for Payer: Anthem Medicaid |
$124.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.75
|
| Rate for Payer: Cash Price |
$181.25
|
| Rate for Payer: Cigna Commercial |
$300.88
|
| Rate for Payer: First Health Commercial |
$344.38
|
| Rate for Payer: Humana Commercial |
$308.12
|
| Rate for Payer: Humana KY Medicaid |
$124.66
|
| Rate for Payer: Kentucky WC Medicaid |
$125.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.00
|
| Rate for Payer: Ohio Health Group HMO |
$271.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$315.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$250.12
|
| Rate for Payer: PHCS Commercial |
$348.00
|
| Rate for Payer: United Healthcare All Payer |
$319.00
|
|
|
MICAFUNGIN 1MG(50MG) SDV
|
Facility
|
IP
|
$362.50
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
25004529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.75 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$279.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.75
|
| Rate for Payer: Cash Price |
$181.25
|
| Rate for Payer: Cigna Commercial |
$300.88
|
| Rate for Payer: First Health Commercial |
$344.38
|
| Rate for Payer: Humana Commercial |
$308.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.00
|
| Rate for Payer: Ohio Health Group HMO |
$271.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$315.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$250.12
|
| Rate for Payer: PHCS Commercial |
$348.00
|
| Rate for Payer: United Healthcare All Payer |
$319.00
|
|
|
MICARDIS 20MG TABLET
|
Facility
|
IP
|
$12.68
|
|
|
Service Code
|
NDC 597003937
|
| Hospital Charge Code |
25000981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$12.17 |
| Rate for Payer: Aetna Commercial |
$9.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.89
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: First Health Commercial |
$12.05
|
| Rate for Payer: Humana Commercial |
$10.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.16
|
| Rate for Payer: Ohio Health Group HMO |
$9.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.75
|
| Rate for Payer: PHCS Commercial |
$12.17
|
| Rate for Payer: United Healthcare All Payer |
$11.16
|
|
|
MICARDIS 20MG TABLET
|
Facility
|
OP
|
$12.68
|
|
|
Service Code
|
NDC 597003937
|
| Hospital Charge Code |
25000981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$12.17 |
| Rate for Payer: Aetna Commercial |
$9.76
|
| Rate for Payer: Anthem Medicaid |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.89
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: First Health Commercial |
$12.05
|
| Rate for Payer: Humana Commercial |
$10.78
|
| Rate for Payer: Humana KY Medicaid |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.16
|
| Rate for Payer: Ohio Health Group HMO |
$9.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.75
|
| Rate for Payer: PHCS Commercial |
$12.17
|
| Rate for Payer: United Healthcare All Payer |
$11.16
|
|
|
MICARDIS 40 MG TABLET
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 68382047278
|
| Hospital Charge Code |
25000982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Humana KY Medicaid |
$3.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
MICARDIS 40 MG TABLET
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 68382047278
|
| Hospital Charge Code |
25000982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
MIC G-TUBE 18FR
|
Facility
|
IP
|
$760.85
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
27000186
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.25 |
| Max. Negotiated Rate |
$730.42 |
| Rate for Payer: Aetna Commercial |
$585.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$593.46
|
| Rate for Payer: Cash Price |
$380.42
|
| Rate for Payer: Cigna Commercial |
$631.51
|
| Rate for Payer: First Health Commercial |
$722.81
|
| Rate for Payer: Humana Commercial |
$646.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$623.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$561.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$669.55
|
| Rate for Payer: Ohio Health Group HMO |
$570.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$608.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$524.99
|
| Rate for Payer: PHCS Commercial |
$730.42
|
| Rate for Payer: United Healthcare All Payer |
$669.55
|
|
|
MIC G-TUBE 18FR
|
Facility
|
OP
|
$760.85
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
27000186
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.25 |
| Max. Negotiated Rate |
$730.42 |
| Rate for Payer: Aetna Commercial |
$585.85
|
| Rate for Payer: Anthem Medicaid |
$261.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$593.46
|
| Rate for Payer: Cash Price |
$380.42
|
| Rate for Payer: Cigna Commercial |
$631.51
|
| Rate for Payer: First Health Commercial |
$722.81
|
| Rate for Payer: Humana Commercial |
$646.72
|
| Rate for Payer: Humana KY Medicaid |
$261.66
|
| Rate for Payer: Kentucky WC Medicaid |
$264.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$623.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$561.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$266.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$669.55
|
| Rate for Payer: Ohio Health Group HMO |
$570.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$608.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$524.99
|
| Rate for Payer: PHCS Commercial |
$730.42
|
| Rate for Payer: United Healthcare All Payer |
$669.55
|
|
|
MIC J-TUBE 18FR 2.3*30CM KIT
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS B4088
|
| Hospital Charge Code |
27000187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
MIC J-TUBE 18FR 2.3*30CM KIT
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS B4088
|
| Hospital Charge Code |
27000187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
MICONAZOLE 2% OINTMENT 71gm
|
Facility
|
OP
|
$5.43
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004440
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna Commercial |
$4.18
|
| Rate for Payer: Anthem Medicaid |
$1.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.24
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna Commercial |
$4.51
|
| Rate for Payer: First Health Commercial |
$5.16
|
| Rate for Payer: Humana Commercial |
$4.62
|
| Rate for Payer: Humana KY Medicaid |
$1.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.78
|
| Rate for Payer: Ohio Health Group HMO |
$4.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.75
|
| Rate for Payer: PHCS Commercial |
$5.21
|
| Rate for Payer: United Healthcare All Payer |
$4.78
|
|
|
MICONAZOLE 2% OINTMENT 71gm
|
Facility
|
IP
|
$5.43
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004440
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna Commercial |
$4.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.24
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna Commercial |
$4.51
|
| Rate for Payer: First Health Commercial |
$5.16
|
| Rate for Payer: Humana Commercial |
$4.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.78
|
| Rate for Payer: Ohio Health Group HMO |
$4.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.75
|
| Rate for Payer: PHCS Commercial |
$5.21
|
| Rate for Payer: United Healthcare All Payer |
$4.78
|
|
|
MICONAZOLE 2% POWDER 85gm
|
Facility
|
IP
|
$5.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004441
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.34
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna Commercial |
$4.61
|
| Rate for Payer: First Health Commercial |
$5.28
|
| Rate for Payer: Humana Commercial |
$4.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.89
|
| Rate for Payer: Ohio Health Group HMO |
$4.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.84
|
| Rate for Payer: PHCS Commercial |
$5.34
|
| Rate for Payer: United Healthcare All Payer |
$4.89
|
|
|
MICONAZOLE 2% POWDER 85gm
|
Facility
|
OP
|
$5.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004441
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Anthem Medicaid |
$1.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.34
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna Commercial |
$4.61
|
| Rate for Payer: First Health Commercial |
$5.28
|
| Rate for Payer: Humana Commercial |
$4.73
|
| Rate for Payer: Humana KY Medicaid |
$1.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.89
|
| Rate for Payer: Ohio Health Group HMO |
$4.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.84
|
| Rate for Payer: PHCS Commercial |
$5.34
|
| Rate for Payer: United Healthcare All Payer |
$4.89
|
|
|
MICRA TRANSCATHETER PACING SYS
|
Facility
|
IP
|
$83,536.00
|
|
|
Service Code
|
HCPCS C1786
|
| Hospital Charge Code |
27000088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,060.80 |
| Max. Negotiated Rate |
$80,194.56 |
| Rate for Payer: Aetna Commercial |
$64,322.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,158.08
|
| Rate for Payer: Cash Price |
$41,768.00
|
| Rate for Payer: Cigna Commercial |
$69,334.88
|
| Rate for Payer: First Health Commercial |
$79,359.20
|
| Rate for Payer: Humana Commercial |
$71,005.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68,499.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,649.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,060.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$73,511.68
|
| Rate for Payer: Ohio Health Group HMO |
$62,652.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66,828.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72,676.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57,639.84
|
| Rate for Payer: PHCS Commercial |
$80,194.56
|
| Rate for Payer: United Healthcare All Payer |
$73,511.68
|
|
|
MICRA TRANSCATHETER PACING SYS
|
Facility
|
OP
|
$83,536.00
|
|
|
Service Code
|
HCPCS C1786
|
| Hospital Charge Code |
27000088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,060.80 |
| Max. Negotiated Rate |
$80,194.56 |
| Rate for Payer: Aetna Commercial |
$64,322.72
|
| Rate for Payer: Anthem Medicaid |
$28,728.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,158.08
|
| Rate for Payer: Cash Price |
$41,768.00
|
| Rate for Payer: Cigna Commercial |
$69,334.88
|
| Rate for Payer: First Health Commercial |
$79,359.20
|
| Rate for Payer: Humana Commercial |
$71,005.60
|
| Rate for Payer: Humana KY Medicaid |
$28,728.03
|
| Rate for Payer: Kentucky WC Medicaid |
$29,020.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68,499.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,649.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,060.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,304.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$73,511.68
|
| Rate for Payer: Ohio Health Group HMO |
$62,652.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66,828.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72,676.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57,639.84
|
| Rate for Payer: PHCS Commercial |
$80,194.56
|
| Rate for Payer: United Healthcare All Payer |
$73,511.68
|
|
|
MICROALBUMIN RANDOM QT.
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 82043
|
| Hospital Charge Code |
30000227
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.40 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$106.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.81
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$114.54
|
| Rate for Payer: First Health Commercial |
$131.10
|
| Rate for Payer: Humana Commercial |
$117.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.44
|
| Rate for Payer: Ohio Health Group HMO |
$103.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.22
|
| Rate for Payer: PHCS Commercial |
$132.48
|
| Rate for Payer: United Healthcare All Payer |
$121.44
|
|
|
MICROALBUMIN RANDOM QT.
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS 82043
|
| Hospital Charge Code |
30000227
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$4.11
|
| Rate for Payer: Ambetter Exchange |
$5.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$5.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$5.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.94
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$5.04
|
| Rate for Payer: Healthspan PPO |
$6.07
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$5.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.78
|
| Rate for Payer: Multiplan PHCS |
$82.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7.51
|
| Rate for Payer: UHCCP Medicaid |
$48.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$5.78
|
|
|
MICROALBUMIN RANDOM QT.
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 82043
|
| Hospital Charge Code |
30000227
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$106.26
|
| Rate for Payer: Anthem Medicaid |
$5.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.78
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$114.54
|
| Rate for Payer: First Health Commercial |
$131.10
|
| Rate for Payer: Humana Commercial |
$117.30
|
| Rate for Payer: Humana KY Medicaid |
$5.78
|
| Rate for Payer: Humana Medicare Advantage |
$5.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.44
|
| Rate for Payer: Ohio Health Group HMO |
$103.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.22
|
| Rate for Payer: PHCS Commercial |
$132.48
|
| Rate for Payer: United Healthcare All Payer |
$121.44
|
|
|
MICRO ASSMBLY LENGTHER HOFFMAN
|
Facility
|
OP
|
$19,141.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,742.40 |
| Max. Negotiated Rate |
$18,375.67 |
| Rate for Payer: Aetna Commercial |
$14,738.82
|
| Rate for Payer: Anthem Medicaid |
$6,582.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,930.23
|
| Rate for Payer: Cash Price |
$9,570.66
|
| Rate for Payer: Cigna Commercial |
$15,887.30
|
| Rate for Payer: First Health Commercial |
$18,184.25
|
| Rate for Payer: Humana Commercial |
$16,270.12
|
| Rate for Payer: Humana KY Medicaid |
$6,582.70
|
| Rate for Payer: Kentucky WC Medicaid |
$6,649.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,695.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,126.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,742.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,714.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,844.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,355.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,313.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,652.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,207.51
|
| Rate for Payer: PHCS Commercial |
$18,375.67
|
| Rate for Payer: United Healthcare All Payer |
$16,844.36
|
|
|
MICRO ASSMBLY LENGTHER HOFFMAN
|
Facility
|
IP
|
$19,141.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,742.40 |
| Max. Negotiated Rate |
$18,375.67 |
| Rate for Payer: Aetna Commercial |
$14,738.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,930.23
|
| Rate for Payer: Cash Price |
$9,570.66
|
| Rate for Payer: Cigna Commercial |
$15,887.30
|
| Rate for Payer: First Health Commercial |
$18,184.25
|
| Rate for Payer: Humana Commercial |
$16,270.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,695.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,126.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,742.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,844.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,355.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,313.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,652.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,207.51
|
| Rate for Payer: PHCS Commercial |
$18,375.67
|
| Rate for Payer: United Healthcare All Payer |
$16,844.36
|
|
|
MICRODOSIMETRY
|
Professional
|
Both
|
$374.00
|
|
|
Service Code
|
HCPCS 77331
|
| Hospital Charge Code |
33300013
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$224.40 |
| Rate for Payer: Aetna Commercial |
$97.31
|
| Rate for Payer: Ambetter Exchange |
$60.75
|
| Rate for Payer: Anthem Medicaid |
$51.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$60.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$72.90
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$93.02
|
| Rate for Payer: Healthspan PPO |
$82.07
|
| Rate for Payer: Humana Medicaid |
$51.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$60.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.07
|
| Rate for Payer: Molina Healthcare Passport |
$51.05
|
| Rate for Payer: Multiplan PHCS |
$224.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.97
|
| Rate for Payer: UHCCP Medicaid |
$130.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$60.75
|
|
