|
AYGESTIN 5MG TABLET
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
25000299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
AZASITE 1% EYE DROPS 2.5 ML
|
Facility
|
IP
|
$17.25
|
|
|
Service Code
|
NDC 82584030703
|
| Hospital Charge Code |
25002868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$13.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.46
|
| Rate for Payer: Cash Price |
$8.62
|
| Rate for Payer: Cigna Commercial |
$14.32
|
| Rate for Payer: First Health Commercial |
$16.39
|
| Rate for Payer: Humana Commercial |
$14.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.18
|
| Rate for Payer: Ohio Health Group HMO |
$12.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.35
|
| Rate for Payer: PHCS Commercial |
$16.56
|
| Rate for Payer: United Healthcare All Payer |
$15.18
|
|
|
AZASITE 1% EYE DROPS 2.5 ML
|
Facility
|
OP
|
$17.25
|
|
|
Service Code
|
NDC 82584030703
|
| Hospital Charge Code |
25002868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$13.28
|
| Rate for Payer: Anthem Medicaid |
$5.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.46
|
| Rate for Payer: Cash Price |
$8.62
|
| Rate for Payer: Cigna Commercial |
$14.32
|
| Rate for Payer: First Health Commercial |
$16.39
|
| Rate for Payer: Humana Commercial |
$14.66
|
| Rate for Payer: Humana KY Medicaid |
$5.93
|
| Rate for Payer: Kentucky WC Medicaid |
$5.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.18
|
| Rate for Payer: Ohio Health Group HMO |
$12.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.35
|
| Rate for Payer: PHCS Commercial |
$16.56
|
| Rate for Payer: United Healthcare All Payer |
$15.18
|
|
|
AZILECT 1MG TAB
|
Facility
|
OP
|
$23.87
|
|
|
Service Code
|
NDC 93306156
|
| Hospital Charge Code |
25000301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$22.92 |
| Rate for Payer: Kentucky WC Medicaid |
$8.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.01
|
| Rate for Payer: Ohio Health Group HMO |
$17.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.40
|
| Rate for Payer: PHCS Commercial |
$22.92
|
| Rate for Payer: United Healthcare All Payer |
$21.01
|
| Rate for Payer: Aetna Commercial |
$18.38
|
| Rate for Payer: Anthem Medicaid |
$8.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.62
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: Cigna Commercial |
$19.81
|
| Rate for Payer: First Health Commercial |
$22.68
|
| Rate for Payer: Humana Commercial |
$20.29
|
| Rate for Payer: Humana KY Medicaid |
$8.21
|
|
|
AZILECT 1MG TAB
|
Facility
|
IP
|
$23.87
|
|
|
Service Code
|
NDC 93306156
|
| Hospital Charge Code |
25000301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$22.92 |
| Rate for Payer: Aetna Commercial |
$18.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.62
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: Cigna Commercial |
$19.81
|
| Rate for Payer: First Health Commercial |
$22.68
|
| Rate for Payer: Humana Commercial |
$20.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.01
|
| Rate for Payer: Ohio Health Group HMO |
$17.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.40
|
| Rate for Payer: PHCS Commercial |
$22.92
|
| Rate for Payer: United Healthcare All Payer |
$21.01
|
|
|
AZOPT 1%OPHTH(BRINZOLAMIDE)5ML
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 68682046410
|
| Hospital Charge Code |
25000302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| 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 |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| 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 |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
AZOPT 1%OPHTH(BRINZOLAMIDE)5ML
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 68682046410
|
| Hospital Charge Code |
25000302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| 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 |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| 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 |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
Aztreonam 100mg (1gm IM)
|
Facility
|
IP
|
$192.08
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$184.40 |
| Rate for Payer: Aetna Commercial |
$147.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.82
|
| Rate for Payer: Cash Price |
$96.04
|
| Rate for Payer: Cigna Commercial |
$159.43
|
| Rate for Payer: First Health Commercial |
$182.48
|
| Rate for Payer: Humana Commercial |
$163.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.03
|
| Rate for Payer: Ohio Health Group HMO |
$144.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.54
|
| Rate for Payer: PHCS Commercial |
$184.40
|
| Rate for Payer: United Healthcare All Payer |
$169.03
|
|
|
Aztreonam 100mg (1gm IM)
|
Facility
|
OP
|
$192.08
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$184.40 |
| Rate for Payer: Aetna Commercial |
$147.90
|
| Rate for Payer: Anthem Medicaid |
$66.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.43
|
| Rate for Payer: Cash Price |
$96.04
|
| Rate for Payer: Cash Price |
$96.04
|
| Rate for Payer: Cigna Commercial |
$159.43
|
| Rate for Payer: First Health Commercial |
$182.48
|
| Rate for Payer: Humana Commercial |
$163.27
|
| Rate for Payer: Humana KY Medicaid |
$66.06
|
| Rate for Payer: Humana Medicare Advantage |
$2.54
|
| Rate for Payer: Kentucky WC Medicaid |
$66.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.03
|
| Rate for Payer: Ohio Health Group HMO |
$144.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.54
|
| Rate for Payer: PHCS Commercial |
$184.40
|
| Rate for Payer: United Healthcare All Payer |
$169.03
|
|
|
Aztreonam 100mg (1gm Syr)
|
Facility
|
IP
|
$192.08
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$184.40 |
| Rate for Payer: Aetna Commercial |
$147.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.82
|
| Rate for Payer: Cash Price |
$96.04
|
| Rate for Payer: Cigna Commercial |
$159.43
|
| Rate for Payer: First Health Commercial |
$182.48
|
| Rate for Payer: Humana Commercial |
$163.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.03
|
| Rate for Payer: Ohio Health Group HMO |
$144.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.54
|
| Rate for Payer: PHCS Commercial |
$184.40
|
| Rate for Payer: United Healthcare All Payer |
$169.03
|
|
|
Aztreonam 100mg (1gm Syr)
|
Facility
|
OP
|
$192.08
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$184.40 |
| Rate for Payer: Aetna Commercial |
$147.90
|
| Rate for Payer: Anthem Medicaid |
$66.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.43
|
| Rate for Payer: Cash Price |
$96.04
|
| Rate for Payer: Cash Price |
$96.04
|
| Rate for Payer: Cigna Commercial |
$159.43
|
| Rate for Payer: First Health Commercial |
$182.48
|
| Rate for Payer: Humana Commercial |
$163.27
|
| Rate for Payer: Humana KY Medicaid |
$66.06
|
| Rate for Payer: Humana Medicare Advantage |
$2.54
|
| Rate for Payer: Kentucky WC Medicaid |
$66.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.03
|
| Rate for Payer: Ohio Health Group HMO |
$144.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.54
|
| Rate for Payer: PHCS Commercial |
$184.40
|
| Rate for Payer: United Healthcare All Payer |
$169.03
|
|
|
Aztreonam 100mg (2m Syr)
|
Facility
|
IP
|
$342.31
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$328.62 |
| Rate for Payer: Aetna Commercial |
$263.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$267.00
|
| Rate for Payer: Cash Price |
$171.16
|
| Rate for Payer: Cigna Commercial |
$284.12
|
| Rate for Payer: First Health Commercial |
$325.19
|
| Rate for Payer: Humana Commercial |
$290.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$280.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$252.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$301.23
|
| Rate for Payer: Ohio Health Group HMO |
$256.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.12
|
| Rate for Payer: PHCS Commercial |
$328.62
|
| Rate for Payer: United Healthcare All Payer |
$301.23
|
|
|
Aztreonam 100mg (2m Syr)
|
Facility
|
OP
|
$342.31
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$328.62 |
| Rate for Payer: Aetna Commercial |
$263.58
|
| Rate for Payer: Anthem Medicaid |
$117.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$267.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.43
|
| Rate for Payer: Cash Price |
$171.16
|
| Rate for Payer: Cash Price |
$171.16
|
| Rate for Payer: Cigna Commercial |
$284.12
|
| Rate for Payer: First Health Commercial |
$325.19
|
| Rate for Payer: Humana Commercial |
$290.96
|
| Rate for Payer: Humana KY Medicaid |
$117.72
|
| Rate for Payer: Humana Medicare Advantage |
$2.54
|
| Rate for Payer: Kentucky WC Medicaid |
$118.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$280.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$252.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$120.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$301.23
|
| Rate for Payer: Ohio Health Group HMO |
$256.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.12
|
| Rate for Payer: PHCS Commercial |
$328.62
|
| Rate for Payer: United Healthcare All Payer |
$301.23
|
|
|
AZULFIDINE(SULFASAL 500MG/1TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 93323401
|
| Hospital Charge Code |
25000303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
AZULFIDINE(SULFASAL 500MG/1TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 93323401
|
| Hospital Charge Code |
25000303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
BABESIA MICROTI AMP PRB
|
Facility
|
IP
|
$169.05
|
|
|
Service Code
|
HCPCS 87469
|
| Hospital Charge Code |
30002061
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.98 |
| Max. Negotiated Rate |
$162.29 |
| Rate for Payer: Aetna Commercial |
$130.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$135.75
|
| Rate for Payer: Cash Price |
$84.53
|
| Rate for Payer: Cigna Commercial |
$140.31
|
| Rate for Payer: First Health Commercial |
$160.60
|
| Rate for Payer: Humana Commercial |
$143.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.76
|
| Rate for Payer: Ohio Health Group HMO |
$126.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.41
|
| Rate for Payer: PHCS Commercial |
$162.29
|
| Rate for Payer: United Healthcare All Payer |
$148.76
|
|
|
BABESIA MICROTI AMP PRB
|
Facility
|
OP
|
$169.05
|
|
|
Service Code
|
HCPCS 87469
|
| Hospital Charge Code |
30002061
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.98 |
| Max. Negotiated Rate |
$162.29 |
| Rate for Payer: Aetna Commercial |
$130.17
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$135.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$84.53
|
| Rate for Payer: Cash Price |
$84.53
|
| Rate for Payer: Cigna Commercial |
$140.31
|
| Rate for Payer: First Health Commercial |
$160.60
|
| Rate for Payer: Humana Commercial |
$143.69
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.76
|
| Rate for Payer: Ohio Health Group HMO |
$126.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.41
|
| Rate for Payer: PHCS Commercial |
$162.29
|
| Rate for Payer: United Healthcare All Payer |
$148.76
|
|
|
BABYGRAM
|
Facility
|
IP
|
$361.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
32000182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.93 |
| Max. Negotiated Rate |
$346.56 |
| Rate for Payer: Aetna Commercial |
$277.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$281.58
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cigna Commercial |
$299.63
|
| Rate for Payer: First Health Commercial |
$342.95
|
| Rate for Payer: Humana Commercial |
$306.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$296.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$266.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$317.68
|
| Rate for Payer: Ohio Health Group HMO |
$270.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$111.91
|
| Rate for Payer: PHCS Commercial |
$346.56
|
| Rate for Payer: United Healthcare All Payer |
$317.68
|
|
|
BABYGRAM
|
Professional
|
Both
|
$361.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
32000182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Aetna Commercial |
$42.50
|
| Rate for Payer: Anthem Medicaid |
$21.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$361.00
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cigna Commercial |
$42.59
|
| Rate for Payer: Healthspan PPO |
$39.82
|
| Rate for Payer: Humana Medicaid |
$21.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.25
|
| Rate for Payer: Molina Healthcare Passport |
$21.81
|
| Rate for Payer: Multiplan PHCS |
$216.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$252.70
|
| Rate for Payer: UHCCP Medicaid |
$126.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.03
|
|
|
BABYGRAM
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
32000182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.93 |
| Max. Negotiated Rate |
$346.56 |
| Rate for Payer: Aetna Commercial |
$277.97
|
| Rate for Payer: Anthem Medicaid |
$124.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$281.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cigna Commercial |
$299.63
|
| Rate for Payer: First Health Commercial |
$342.95
|
| Rate for Payer: Humana Commercial |
$306.85
|
| Rate for Payer: Humana KY Medicaid |
$124.15
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$125.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$296.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$266.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$126.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$317.68
|
| Rate for Payer: Ohio Health Group HMO |
$270.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$111.91
|
| Rate for Payer: PHCS Commercial |
$346.56
|
| Rate for Payer: United Healthcare All Payer |
$317.68
|
|
|
BABYGRAM(P
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
320P0182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$42.59 |
| Rate for Payer: Aetna Commercial |
$42.50
|
| Rate for Payer: Anthem Medicaid |
$21.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.00
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$42.59
|
| Rate for Payer: Healthspan PPO |
$39.82
|
| Rate for Payer: Humana Medicaid |
$21.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.25
|
| Rate for Payer: Molina Healthcare Passport |
$21.81
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.03
|
|
|
BABYGRAM(T
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
320T0182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$312.96 |
| Rate for Payer: Aetna Commercial |
$251.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$254.28
|
| Rate for Payer: Cash Price |
$163.00
|
| Rate for Payer: Cigna Commercial |
$270.58
|
| Rate for Payer: First Health Commercial |
$309.70
|
| Rate for Payer: Humana Commercial |
$277.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$267.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$240.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.88
|
| Rate for Payer: Ohio Health Group HMO |
$244.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.06
|
| Rate for Payer: PHCS Commercial |
$312.96
|
| Rate for Payer: United Healthcare All Payer |
$286.88
|
|
|
BABYGRAM(T
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
320T0182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$312.96 |
| Rate for Payer: Aetna Commercial |
$251.02
|
| Rate for Payer: Anthem Medicaid |
$112.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$254.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$163.00
|
| Rate for Payer: Cash Price |
$163.00
|
| Rate for Payer: Cigna Commercial |
$270.58
|
| Rate for Payer: First Health Commercial |
$309.70
|
| Rate for Payer: Humana Commercial |
$277.10
|
| Rate for Payer: Humana KY Medicaid |
$112.11
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$113.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$267.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$240.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.88
|
| Rate for Payer: Ohio Health Group HMO |
$244.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.06
|
| Rate for Payer: PHCS Commercial |
$312.96
|
| Rate for Payer: United Healthcare All Payer |
$286.88
|
|
|
BACITRACIN EYE OINT (3.5GM)
|
Facility
|
IP
|
$17.54
|
|
|
Service Code
|
NDC 574402235
|
| Hospital Charge Code |
25000304
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$16.84 |
| Rate for Payer: Aetna Commercial |
$13.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.68
|
| Rate for Payer: Cash Price |
$8.77
|
| Rate for Payer: Cigna Commercial |
$14.56
|
| Rate for Payer: First Health Commercial |
$16.66
|
| Rate for Payer: Humana Commercial |
$14.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.44
|
| Rate for Payer: Ohio Health Group HMO |
$13.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.44
|
| Rate for Payer: PHCS Commercial |
$16.84
|
| Rate for Payer: United Healthcare All Payer |
$15.44
|
|
|
BACITRACIN EYE OINT (3.5GM)
|
Facility
|
OP
|
$17.54
|
|
|
Service Code
|
NDC 574402235
|
| Hospital Charge Code |
25000304
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$16.84 |
| Rate for Payer: Aetna Commercial |
$13.51
|
| Rate for Payer: Anthem Medicaid |
$6.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.68
|
| Rate for Payer: Cash Price |
$8.77
|
| Rate for Payer: Cigna Commercial |
$14.56
|
| Rate for Payer: First Health Commercial |
$16.66
|
| Rate for Payer: Humana Commercial |
$14.91
|
| Rate for Payer: Humana KY Medicaid |
$6.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.44
|
| Rate for Payer: Ohio Health Group HMO |
$13.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.44
|
| Rate for Payer: PHCS Commercial |
$16.84
|
| Rate for Payer: United Healthcare All Payer |
$15.44
|
|
