|
AUGMENT 25062.5MG/5ML EQ100ML
|
Facility
|
OP
|
$11.46
|
|
|
Service Code
|
NDC 60432006500
|
| Hospital Charge Code |
25002861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Anthem Medicaid |
$3.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.94
|
| Rate for Payer: Cash Price |
$5.73
|
| Rate for Payer: Cigna Commercial |
$9.51
|
| Rate for Payer: First Health Commercial |
$10.89
|
| Rate for Payer: Humana Commercial |
$9.74
|
| Rate for Payer: Humana KY Medicaid |
$3.94
|
| Rate for Payer: Kentucky WC Medicaid |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.08
|
| Rate for Payer: Ohio Health Group HMO |
$8.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.55
|
| Rate for Payer: PHCS Commercial |
$11.00
|
| Rate for Payer: United Healthcare All Payer |
$10.08
|
|
|
AUGMENTATION LOWER JAW BONE
|
Facility
|
OP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21125
|
| Hospital Charge Code |
76100373
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$903.11 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem Medicaid |
$2,389.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Humana KY Medicaid |
$2,389.07
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,413.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,437.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$903.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,153.57
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
AUGMENTATION LOWER JAW BONE
|
Facility
|
IP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21125
|
| Hospital Charge Code |
76100373
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$903.11 |
| Max. Negotiated Rate |
$6,669.12 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,084.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$903.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,153.57
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
AUGMENTATION LOWER JAW BONE
|
Facility
|
IP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21125
|
| Hospital Charge Code |
45000098
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$903.11 |
| Max. Negotiated Rate |
$6,669.12 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,084.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$903.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,153.57
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
AUGMENTATION LOWER JAW BONE
|
Facility
|
OP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21125
|
| Hospital Charge Code |
45000098
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$903.11 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem Medicaid |
$2,389.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Humana KY Medicaid |
$2,389.07
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,413.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,437.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$903.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,153.57
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
AUGMENTATIVE EVAL 1ST HR
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
HCPCS 92605
|
| Hospital Charge Code |
44000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem Medicaid |
$178.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Humana KY Medicaid |
$178.48
|
| Rate for Payer: Kentucky WC Medicaid |
$180.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
AUGMENTATIVE EVAL 1ST HR
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
HCPCS 92605
|
| Hospital Charge Code |
44000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
AUGMENTATIVE EVAL EA AD30 MIN
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 92618
|
| Hospital Charge Code |
44000015
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Aetna Commercial |
$186.34
|
| Rate for Payer: Anthem Medicaid |
$83.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: First Health Commercial |
$229.90
|
| Rate for Payer: Humana Commercial |
$205.70
|
| Rate for Payer: Humana KY Medicaid |
$83.22
|
| Rate for Payer: Kentucky WC Medicaid |
$84.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
| Rate for Payer: Ohio Health Group HMO |
$181.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
AUGMENTATIVE EVAL EA AD30 MIN
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 92618
|
| Hospital Charge Code |
44000015
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Aetna Commercial |
$186.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: First Health Commercial |
$229.90
|
| Rate for Payer: Humana Commercial |
$205.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
| Rate for Payer: Ohio Health Group HMO |
$181.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
AUGMENTIN 200 MG/5 ML 50 MLBOT
|
Facility
|
IP
|
$5.06
|
|
|
Service Code
|
NDC 781610252
|
| Hospital Charge Code |
25000285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cigna Commercial |
$4.20
|
| Rate for Payer: First Health Commercial |
$4.81
|
| Rate for Payer: Humana Commercial |
$4.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.45
|
| Rate for Payer: Ohio Health Group HMO |
$3.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
AUGMENTIN 200 MG/5 ML 50 MLBOT
|
Facility
|
OP
|
$5.06
|
|
|
Service Code
|
NDC 781610252
|
| Hospital Charge Code |
25000285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cigna Commercial |
$4.20
|
| Rate for Payer: First Health Commercial |
$4.81
|
| Rate for Payer: Humana Commercial |
$4.30
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.45
|
| Rate for Payer: Ohio Health Group HMO |
$3.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
AUGMENTIN 600MG/5ML SUSPENSION
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 781613948
|
| Hospital Charge Code |
25000286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| 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 |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| 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 |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
AUGMENTIN 600MG/5ML SUSPENSION
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 781613948
|
| Hospital Charge Code |
25000286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| 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 |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| 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 |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
AUGMENTIN (AMOX/CLAV) 500MG/1T
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 65862050220
|
| Hospital Charge Code |
25002859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
AUGMENTIN (AMOX/CLAV) 500MG/1T
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 65862050220
|
| Hospital Charge Code |
25002859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
AUGMENTIN (AMOX/CLV) 875MG/1T)
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 65862050320
|
| Hospital Charge Code |
25002860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
AUGMENTIN (AMOX/CLV) 875MG/1T)
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 65862050320
|
| Hospital Charge Code |
25002860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
AUGMENTIN EQ 400MG/5ML SUSP
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 66685101201
|
| Hospital Charge Code |
25002862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.72
|
| Rate for Payer: Humana Commercial |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.37
|
| Rate for Payer: Ohio Health Group HMO |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
AUGMENTIN EQ 400MG/5ML SUSP
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 66685101201
|
| Hospital Charge Code |
25002862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem Medicaid |
$1.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.72
|
| Rate for Payer: Humana Commercial |
$4.22
|
| Rate for Payer: Humana KY Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.37
|
| Rate for Payer: Ohio Health Group HMO |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 L
|
Facility
|
IP
|
$10,892.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.96 |
| Max. Negotiated Rate |
$10,456.32 |
| Rate for Payer: Aetna Commercial |
$8,386.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,495.76
|
| Rate for Payer: Cash Price |
$5,446.00
|
| Rate for Payer: Cigna Commercial |
$9,040.36
|
| Rate for Payer: First Health Commercial |
$10,347.40
|
| Rate for Payer: Humana Commercial |
$9,258.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,931.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,038.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,267.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,584.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,169.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,178.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,415.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.52
|
| Rate for Payer: PHCS Commercial |
$10,456.32
|
| Rate for Payer: United Healthcare All Payer |
$9,584.96
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 L
|
Facility
|
OP
|
$10,892.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.96 |
| Max. Negotiated Rate |
$10,456.32 |
| Rate for Payer: Aetna Commercial |
$8,386.84
|
| Rate for Payer: Anthem Medicaid |
$3,745.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,495.76
|
| Rate for Payer: Cash Price |
$5,446.00
|
| Rate for Payer: Cigna Commercial |
$9,040.36
|
| Rate for Payer: First Health Commercial |
$10,347.40
|
| Rate for Payer: Humana Commercial |
$9,258.20
|
| Rate for Payer: Humana KY Medicaid |
$3,745.76
|
| Rate for Payer: Kentucky WC Medicaid |
$3,783.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,931.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,038.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,267.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,820.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,584.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,169.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,178.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,415.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.52
|
| Rate for Payer: PHCS Commercial |
$10,456.32
|
| Rate for Payer: United Healthcare All Payer |
$9,584.96
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 R
|
Facility
|
OP
|
$10,892.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.96 |
| Max. Negotiated Rate |
$10,456.32 |
| Rate for Payer: Aetna Commercial |
$8,386.84
|
| Rate for Payer: Anthem Medicaid |
$3,745.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,495.76
|
| Rate for Payer: Cash Price |
$5,446.00
|
| Rate for Payer: Cigna Commercial |
$9,040.36
|
| Rate for Payer: First Health Commercial |
$10,347.40
|
| Rate for Payer: Humana Commercial |
$9,258.20
|
| Rate for Payer: Humana KY Medicaid |
$3,745.76
|
| Rate for Payer: Kentucky WC Medicaid |
$3,783.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,931.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,038.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,267.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,820.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,584.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,169.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,178.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,415.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.52
|
| Rate for Payer: PHCS Commercial |
$10,456.32
|
| Rate for Payer: United Healthcare All Payer |
$9,584.96
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 R
|
Facility
|
IP
|
$10,892.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.96 |
| Max. Negotiated Rate |
$10,456.32 |
| Rate for Payer: Aetna Commercial |
$8,386.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,495.76
|
| Rate for Payer: Cash Price |
$5,446.00
|
| Rate for Payer: Cigna Commercial |
$9,040.36
|
| Rate for Payer: First Health Commercial |
$10,347.40
|
| Rate for Payer: Humana Commercial |
$9,258.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,931.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,038.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,267.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,584.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,169.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,178.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,415.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.52
|
| Rate for Payer: PHCS Commercial |
$10,456.32
|
| Rate for Payer: United Healthcare All Payer |
$9,584.96
|
|
|
AUGMENT LEGION UNIVERSAL SZ5 L
|
Facility
|
IP
|
$10,892.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.96 |
| Max. Negotiated Rate |
$10,456.32 |
| Rate for Payer: Aetna Commercial |
$8,386.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,495.76
|
| Rate for Payer: Cash Price |
$5,446.00
|
| Rate for Payer: Cigna Commercial |
$9,040.36
|
| Rate for Payer: First Health Commercial |
$10,347.40
|
| Rate for Payer: Humana Commercial |
$9,258.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,931.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,038.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,267.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,584.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,169.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,178.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,415.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.52
|
| Rate for Payer: PHCS Commercial |
$10,456.32
|
| Rate for Payer: United Healthcare All Payer |
$9,584.96
|
|
|
AUGMENT LEGION UNIVERSAL SZ5 L
|
Facility
|
OP
|
$10,892.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.96 |
| Max. Negotiated Rate |
$10,456.32 |
| Rate for Payer: Aetna Commercial |
$8,386.84
|
| Rate for Payer: Anthem Medicaid |
$3,745.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,495.76
|
| Rate for Payer: Cash Price |
$5,446.00
|
| Rate for Payer: Cigna Commercial |
$9,040.36
|
| Rate for Payer: First Health Commercial |
$10,347.40
|
| Rate for Payer: Humana Commercial |
$9,258.20
|
| Rate for Payer: Humana KY Medicaid |
$3,745.76
|
| Rate for Payer: Kentucky WC Medicaid |
$3,783.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,931.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,038.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,267.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,820.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,584.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,169.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,178.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,415.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.52
|
| Rate for Payer: PHCS Commercial |
$10,456.32
|
| Rate for Payer: United Healthcare All Payer |
$9,584.96
|
|
