|
MINOCIN 1MG [100MGVIAL]
|
Facility
|
IP
|
$838.50
|
|
|
Service Code
|
HCPCS J2265
|
| Hospital Charge Code |
25002242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$251.55 |
| Max. Negotiated Rate |
$804.96 |
| Rate for Payer: Aetna Commercial |
$645.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$654.03
|
| Rate for Payer: Cash Price |
$419.25
|
| Rate for Payer: Cigna Commercial |
$695.96
|
| Rate for Payer: First Health Commercial |
$796.58
|
| Rate for Payer: Humana Commercial |
$712.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$618.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$737.88
|
| Rate for Payer: Ohio Health Group HMO |
$628.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$670.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$578.57
|
| Rate for Payer: PHCS Commercial |
$804.96
|
| Rate for Payer: United Healthcare All Payer |
$737.88
|
|
|
MINOCIN (MINOCYCLINE 50MG/1CAP
|
Facility
|
IP
|
$9.70
|
|
|
Service Code
|
NDC 50090301603
|
| Hospital Charge Code |
25000991
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Aetna Commercial |
$7.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.57
|
| Rate for Payer: Cash Price |
$4.85
|
| Rate for Payer: Cigna Commercial |
$8.05
|
| Rate for Payer: First Health Commercial |
$9.21
|
| Rate for Payer: Humana Commercial |
$8.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.54
|
| Rate for Payer: Ohio Health Group HMO |
$7.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.69
|
| Rate for Payer: PHCS Commercial |
$9.31
|
| Rate for Payer: United Healthcare All Payer |
$8.54
|
|
|
MINOCIN (MINOCYCLINE 50MG/1CAP
|
Facility
|
OP
|
$9.70
|
|
|
Service Code
|
NDC 50090301603
|
| Hospital Charge Code |
25000991
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Aetna Commercial |
$7.47
|
| Rate for Payer: Anthem Medicaid |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.57
|
| Rate for Payer: Cash Price |
$4.85
|
| Rate for Payer: Cigna Commercial |
$8.05
|
| Rate for Payer: First Health Commercial |
$9.21
|
| Rate for Payer: Humana Commercial |
$8.24
|
| Rate for Payer: Humana KY Medicaid |
$3.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.54
|
| Rate for Payer: Ohio Health Group HMO |
$7.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.69
|
| Rate for Payer: PHCS Commercial |
$9.31
|
| Rate for Payer: United Healthcare All Payer |
$8.54
|
|
|
MIOCHOL(ACETYLCHOLINE) OPH 2ML
|
Facility
|
OP
|
$558.57
|
|
|
Service Code
|
NDC 24208053920
|
| Hospital Charge Code |
25000992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.57 |
| Max. Negotiated Rate |
$536.23 |
| Rate for Payer: Aetna Commercial |
$430.10
|
| Rate for Payer: Anthem Medicaid |
$192.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.68
|
| Rate for Payer: Cash Price |
$279.29
|
| Rate for Payer: Cigna Commercial |
$463.61
|
| Rate for Payer: First Health Commercial |
$530.64
|
| Rate for Payer: Humana Commercial |
$474.78
|
| Rate for Payer: Humana KY Medicaid |
$192.09
|
| Rate for Payer: Kentucky WC Medicaid |
$194.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$195.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.54
|
| Rate for Payer: Ohio Health Group HMO |
$418.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$446.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.41
|
| Rate for Payer: PHCS Commercial |
$536.23
|
| Rate for Payer: United Healthcare All Payer |
$491.54
|
|
|
MIOCHOL(ACETYLCHOLINE) OPH 2ML
|
Facility
|
IP
|
$558.57
|
|
|
Service Code
|
NDC 24208053920
|
| Hospital Charge Code |
25000992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.57 |
| Max. Negotiated Rate |
$536.23 |
| Rate for Payer: Aetna Commercial |
$430.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.68
|
| Rate for Payer: Cash Price |
$279.29
|
| Rate for Payer: Cigna Commercial |
$463.61
|
| Rate for Payer: First Health Commercial |
$530.64
|
| Rate for Payer: Humana Commercial |
$474.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.54
|
| Rate for Payer: Ohio Health Group HMO |
$418.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$446.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.41
|
| Rate for Payer: PHCS Commercial |
$536.23
|
| Rate for Payer: United Healthcare All Payer |
$491.54
|
|
|
MIOSTAT (CARBACHOL) 0.01 1.5ML
|
Facility
|
OP
|
$202.47
|
|
|
Service Code
|
NDC 65002315
|
| Hospital Charge Code |
25000993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.74 |
| Max. Negotiated Rate |
$194.37 |
| Rate for Payer: Aetna Commercial |
$155.90
|
| Rate for Payer: Anthem Medicaid |
$69.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.93
|
| Rate for Payer: Cash Price |
$101.24
|
| Rate for Payer: Cigna Commercial |
$168.05
|
| Rate for Payer: First Health Commercial |
$192.35
|
| Rate for Payer: Humana Commercial |
$172.10
|
| Rate for Payer: Humana KY Medicaid |
$69.63
|
| Rate for Payer: Kentucky WC Medicaid |
$70.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.17
|
| Rate for Payer: Ohio Health Group HMO |
$151.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$161.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.70
|
| Rate for Payer: PHCS Commercial |
$194.37
|
| Rate for Payer: United Healthcare All Payer |
$178.17
|
|
|
MIOSTAT (CARBACHOL) 0.01 1.5ML
|
Facility
|
IP
|
$202.47
|
|
|
Service Code
|
NDC 65002315
|
| Hospital Charge Code |
25000993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.74 |
| Max. Negotiated Rate |
$194.37 |
| Rate for Payer: Aetna Commercial |
$155.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.93
|
| Rate for Payer: Cash Price |
$101.24
|
| Rate for Payer: Cigna Commercial |
$168.05
|
| Rate for Payer: First Health Commercial |
$192.35
|
| Rate for Payer: Humana Commercial |
$172.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.17
|
| Rate for Payer: Ohio Health Group HMO |
$151.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$161.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.70
|
| Rate for Payer: PHCS Commercial |
$194.37
|
| Rate for Payer: United Healthcare All Payer |
$178.17
|
|
|
MIRACLE BROS 12 PTCA GW 300CM
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem Medicaid |
$603.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Humana KY Medicaid |
$603.89
|
| Rate for Payer: Kentucky WC Medicaid |
$610.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
MIRACLE BROS 12 PTCA GW 300CM
|
Facility
|
IP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
MIRACLE BROS 6 PTCA GW 300CM
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem Medicaid |
$603.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Humana KY Medicaid |
$603.89
|
| Rate for Payer: Kentucky WC Medicaid |
$610.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
MIRACLE BROS 6 PTCA GW 300CM
|
Facility
|
IP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
MIRALAX EQUIV(238GM) POWDER
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 45802086802
|
| Hospital Charge Code |
25000996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| 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
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
MIRALAX (POLYETHIENE) 17 GRAM
|
Facility
|
IP
|
$9.13
|
|
|
Service Code
|
NDC 11523726808
|
| Hospital Charge Code |
25000994
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$8.76 |
| 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
|
| 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 |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.30
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
MIRALAX (POLYETHIENE) 17 GRAM
|
Facility
|
OP
|
$9.13
|
|
|
Service Code
|
NDC 11523726808
|
| Hospital Charge Code |
25000994
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| 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 |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.30
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
MIRAPEX 0.125 MG TABLET
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 13668009190
|
| Hospital Charge Code |
25000997
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| 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 |
$1.30 |
| 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 |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
MIRAPEX 0.25 MG TABLET
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 60687057001
|
| Hospital Charge Code |
25000998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| 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 |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| 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 |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
MIRAPEX 0.25 MG TABLET
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 60687057001
|
| Hospital Charge Code |
25000998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| 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 |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| 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 |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
MIRAPEX 0.5 MG TABLET
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
NDC 60687058121
|
| Hospital Charge Code |
25000999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| 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 |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.47
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
MIRAPEX 0.5 MG TABLET
|
Facility
|
OP
|
$5.03
|
|
|
Service Code
|
NDC 60687058121
|
| Hospital Charge Code |
25000999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.83 |
| 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
|
| 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 |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.47
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
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 |
$525.00 |
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
$525.00 |
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
63600071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| 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 |
$601.83
|
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
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 |
$1,445.41 |
| Rate for Payer: Aetna Commercial |
$1,366.87
|
| 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
|
|
