|
MOLD DEFINITIVE IDENTIFICATION
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 87107
|
| Hospital Charge Code |
30001278
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$10.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.32
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$10.32
|
| Rate for Payer: Humana Medicare Advantage |
$10.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
MONISTAT 7(MICONAZOL 100MG/1EA
|
Facility
|
IP
|
$9.17
|
|
|
Service Code
|
NDC 61269073607
|
| Hospital Charge Code |
25001007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna Commercial |
$7.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.15
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna Commercial |
$7.61
|
| Rate for Payer: First Health Commercial |
$8.71
|
| Rate for Payer: Humana Commercial |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.07
|
| Rate for Payer: Ohio Health Group HMO |
$6.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.33
|
| Rate for Payer: PHCS Commercial |
$8.80
|
| Rate for Payer: United Healthcare All Payer |
$8.07
|
|
|
MONISTAT 7(MICONAZOL 100MG/1EA
|
Facility
|
OP
|
$9.17
|
|
|
Service Code
|
NDC 61269073607
|
| Hospital Charge Code |
25001007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna Commercial |
$7.06
|
| Rate for Payer: Anthem Medicaid |
$3.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.15
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna Commercial |
$7.61
|
| Rate for Payer: First Health Commercial |
$8.71
|
| Rate for Payer: Humana Commercial |
$7.79
|
| Rate for Payer: Humana KY Medicaid |
$3.15
|
| Rate for Payer: Kentucky WC Medicaid |
$3.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.07
|
| Rate for Payer: Ohio Health Group HMO |
$6.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.33
|
| Rate for Payer: PHCS Commercial |
$8.80
|
| Rate for Payer: United Healthcare All Payer |
$8.07
|
|
|
MONISTAT 7(MICONAZOLE) CR 45GM
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 24385059029
|
| Hospital Charge Code |
25001008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna Commercial |
$0.45
|
| Rate for Payer: Anthem Medicaid |
$0.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.49
|
| Rate for Payer: First Health Commercial |
$0.56
|
| Rate for Payer: Humana Commercial |
$0.50
|
| Rate for Payer: Humana KY Medicaid |
$0.20
|
| Rate for Payer: Kentucky WC Medicaid |
$0.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.52
|
| Rate for Payer: Ohio Health Group HMO |
$0.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Payer |
$0.52
|
|
|
MONISTAT 7(MICONAZOLE) CR 45GM
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 24385059029
|
| Hospital Charge Code |
25001008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna Commercial |
$0.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.49
|
| Rate for Payer: First Health Commercial |
$0.56
|
| Rate for Payer: Humana Commercial |
$0.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.52
|
| Rate for Payer: Ohio Health Group HMO |
$0.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Payer |
$0.52
|
|
|
MONISTAT DERM (MICONAZOLE 15GM
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 51672200101
|
| Hospital Charge Code |
25001009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna Commercial |
$0.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.18
|
| Rate for Payer: First Health Commercial |
$0.21
|
| Rate for Payer: Humana Commercial |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.19
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| Rate for Payer: PHCS Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Payer |
$0.19
|
|
|
MONISTAT DERM (MICONAZOLE 15GM
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 51672200101
|
| Hospital Charge Code |
25001009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna Commercial |
$0.17
|
| Rate for Payer: Anthem Medicaid |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.18
|
| Rate for Payer: First Health Commercial |
$0.21
|
| Rate for Payer: Humana Commercial |
$0.19
|
| Rate for Payer: Humana KY Medicaid |
$0.08
|
| Rate for Payer: Kentucky WC Medicaid |
$0.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.19
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| Rate for Payer: PHCS Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Payer |
$0.19
|
|
|
MONOFERRIC 10mg (1,000mg)
|
Facility
|
IP
|
$19,138.82
|
|
|
Service Code
|
HCPCS J1437
|
| Hospital Charge Code |
25004131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,741.65 |
| Max. Negotiated Rate |
$18,373.27 |
| Rate for Payer: Aetna Commercial |
$14,736.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,928.28
|
| Rate for Payer: Cash Price |
$9,569.41
|
| Rate for Payer: Cigna Commercial |
$15,885.22
|
| Rate for Payer: First Health Commercial |
$18,181.88
|
| Rate for Payer: Humana Commercial |
$16,268.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,693.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,124.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,741.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,842.16
|
| Rate for Payer: Ohio Health Group HMO |
$14,354.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,311.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,650.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,205.79
|
| Rate for Payer: PHCS Commercial |
$18,373.27
|
| Rate for Payer: United Healthcare All Payer |
$16,842.16
|
|
|
MONOFERRIC 10mg (1,000mg)
|
Facility
|
OP
|
$19,138.82
|
|
|
Service Code
|
HCPCS J1437
|
| Hospital Charge Code |
25004131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.95 |
| Max. Negotiated Rate |
$18,373.27 |
| Rate for Payer: Aetna Commercial |
$14,736.89
|
| Rate for Payer: Anthem Medicaid |
$6,581.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,928.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$26.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.58
|
| Rate for Payer: Cash Price |
$9,569.41
|
| Rate for Payer: Cash Price |
$9,569.41
|
| Rate for Payer: Cigna Commercial |
$15,885.22
|
| Rate for Payer: First Health Commercial |
$18,181.88
|
| Rate for Payer: Humana Commercial |
$16,268.00
|
| Rate for Payer: Humana KY Medicaid |
$6,581.84
|
| Rate for Payer: Humana Medicare Advantage |
$18.95
|
| Rate for Payer: Kentucky WC Medicaid |
$6,648.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,693.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,124.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,713.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,842.16
|
| Rate for Payer: Ohio Health Group HMO |
$14,354.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,311.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,650.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,205.79
|
| Rate for Payer: PHCS Commercial |
$18,373.27
|
| Rate for Payer: United Healthcare All Payer |
$16,842.16
|
|
|
MONOPRIL 40MG EQUIVALENT TAB
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 69097085805
|
| Hospital Charge Code |
25003214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| 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 |
$1.36 |
| 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 |
$3.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MONOPRIL (FOSINOPRIL 10MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 43547038609
|
| Hospital Charge Code |
25001010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
MONOPRIL (FOSINOPRIL 10MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 43547038609
|
| Hospital Charge Code |
25001010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
MONO TEST
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
30001041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem Medicaid |
$5.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.18
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| 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 |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
MONO TEST
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
30001041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.15
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
MONO TEST
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
30001041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$8.98
|
| Rate for Payer: Ambetter Exchange |
$5.18
|
| Rate for Payer: Buckeye Individual/Medicaid |
$5.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$5.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.22
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$7.28
|
| Rate for Payer: Healthspan PPO |
$5.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$5.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.18
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$6.73
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$5.18
|
|
|
MONSEL 8ML
|
Facility
|
IP
|
$91.09
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004418
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$27.33 |
| 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 |
$72.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.85
|
| Rate for Payer: PHCS Commercial |
$87.45
|
| Rate for Payer: United Healthcare All Payer |
$80.16
|
|
|
MONSEL 8ML
|
Facility
|
OP
|
$91.09
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004418
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$27.33 |
| 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 |
$72.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.85
|
| Rate for Payer: PHCS Commercial |
$87.45
|
| Rate for Payer: United Healthcare All Payer |
$80.16
|
|
|
MONSEL FERRIC SUBSULF SOL(8ML)
|
Facility
|
IP
|
$90.65
|
|
|
Service Code
|
NDC 59365606500
|
| Hospital Charge Code |
25003217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| 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 |
$72.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.55
|
| Rate for Payer: PHCS Commercial |
$87.02
|
| Rate for Payer: United Healthcare All Payer |
$79.77
|
|
|
MONSEL FERRIC SUBSULF SOL(8ML)
|
Facility
|
OP
|
$90.65
|
|
|
Service Code
|
NDC 59365606500
|
| Hospital Charge Code |
25003217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| 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 |
$72.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.55
|
| Rate for Payer: PHCS Commercial |
$87.02
|
| Rate for Payer: United Healthcare All Payer |
$79.77
|
|
|
MONSELS[FERRIC SULF]SOLU 20ML
|
Facility
|
IP
|
$78.88
|
|
|
Service Code
|
NDC 38779128405
|
| Hospital Charge Code |
25003218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.66 |
| 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 |
$63.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.43
|
| Rate for Payer: PHCS Commercial |
$75.72
|
| Rate for Payer: United Healthcare All Payer |
$69.41
|
|
|
MONSELS[FERRIC SULF]SOLU 20ML
|
Facility
|
OP
|
$78.88
|
|
|
Service Code
|
NDC 38779128405
|
| Hospital Charge Code |
25003218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.66 |
| 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 |
$63.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.43
|
| Rate for Payer: PHCS Commercial |
$75.72
|
| Rate for Payer: United Healthcare All Payer |
$69.41
|
|
|
MONTAGE PATIENT TRIAL KIT
|
Facility
|
OP
|
$1,213.20
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$363.96 |
| Max. Negotiated Rate |
$1,164.67 |
| Rate for Payer: Aetna Commercial |
$934.16
|
| Rate for Payer: Anthem Medicaid |
$417.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$946.30
|
| Rate for Payer: Cash Price |
$606.60
|
| Rate for Payer: Cigna Commercial |
$1,006.96
|
| Rate for Payer: First Health Commercial |
$1,152.54
|
| Rate for Payer: Humana Commercial |
$1,031.22
|
| Rate for Payer: Humana KY Medicaid |
$417.22
|
| Rate for Payer: Kentucky WC Medicaid |
$421.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$994.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$895.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$363.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$425.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,067.62
|
| Rate for Payer: Ohio Health Group HMO |
$909.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$970.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,055.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$837.11
|
| Rate for Payer: PHCS Commercial |
$1,164.67
|
| Rate for Payer: United Healthcare All Payer |
$1,067.62
|
|
|
MONTAGE PATIENT TRIAL KIT
|
Facility
|
IP
|
$1,213.20
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$363.96 |
| Max. Negotiated Rate |
$1,164.67 |
| Rate for Payer: Aetna Commercial |
$934.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$946.30
|
| Rate for Payer: Cash Price |
$606.60
|
| Rate for Payer: Cigna Commercial |
$1,006.96
|
| Rate for Payer: First Health Commercial |
$1,152.54
|
| Rate for Payer: Humana Commercial |
$1,031.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$994.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$895.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$363.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,067.62
|
| Rate for Payer: Ohio Health Group HMO |
$909.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$970.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,055.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$837.11
|
| Rate for Payer: PHCS Commercial |
$1,164.67
|
| Rate for Payer: United Healthcare All Payer |
$1,067.62
|
|
|
MONTAGE PUL GEN FULL BDY MRI S
|
Facility
|
OP
|
$91,440.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27,432.00 |
| Max. Negotiated Rate |
$87,782.40 |
| Rate for Payer: Aetna Commercial |
$70,408.80
|
| Rate for Payer: Anthem Medicaid |
$31,446.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71,323.20
|
| Rate for Payer: Cash Price |
$45,720.00
|
| Rate for Payer: Cigna Commercial |
$75,895.20
|
| Rate for Payer: First Health Commercial |
$86,868.00
|
| Rate for Payer: Humana Commercial |
$77,724.00
|
| Rate for Payer: Humana KY Medicaid |
$31,446.22
|
| Rate for Payer: Kentucky WC Medicaid |
$31,766.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74,980.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67,482.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27,432.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$32,077.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$80,467.20
|
| Rate for Payer: Ohio Health Group HMO |
$68,580.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73,152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79,552.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63,093.60
|
| Rate for Payer: PHCS Commercial |
$87,782.40
|
| Rate for Payer: United Healthcare All Payer |
$80,467.20
|
|
