|
BENICAR(OLMESARTAN)20MG TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 68462043730
|
| Hospital Charge Code |
25000322
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
BENICAR (OLMESARTAN) 40 MG TAB
|
Facility
|
IP
|
$4.54
|
|
|
Service Code
|
NDC 378712493
|
| Hospital Charge Code |
25000320
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| 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 |
$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 |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
BENICAR (OLMESARTAN) 40 MG TAB
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 378712493
|
| Hospital Charge Code |
25000320
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| 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 |
$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 |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
BENIGN DESTRCTN 31-40 LESIONS
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200357
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
BENIGN DESTRCTN 41-50 LESIONS
|
Professional
|
Both
|
$325.00
|
|
| Hospital Charge Code |
22200356
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$325.00
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
|
|
BENIGN DESTRUCTION 51+ LESIONS
|
Professional
|
Both
|
$400.00
|
|
| Hospital Charge Code |
22200355
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
BENIGN DESTRUCTN 1-10 LESIONS
|
Professional
|
Both
|
$125.00
|
|
| Hospital Charge Code |
22200328
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
|
|
BENIGN DESTRUCTN 11-20 LESIONS
|
Professional
|
Both
|
$175.00
|
|
| Hospital Charge Code |
22200329
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
|
|
BENIGN DESTRUCTN 21+ LESIONS
|
Professional
|
Both
|
$200.00
|
|
| Hospital Charge Code |
22200330
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
|
BENIGN PROSTATIC HYPERTROPHY WITH MCC
|
Facility
|
IP
|
$14,516.31
|
|
|
Service Code
|
MSDRG 725
|
| Min. Negotiated Rate |
$9,850.35 |
| Max. Negotiated Rate |
$14,516.31 |
| Rate for Payer: Anthem Medicaid |
$9,850.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,368.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14,516.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,997.87
|
| Rate for Payer: Humana KY Medicaid |
$9,850.35
|
| Rate for Payer: Humana Medicare Advantage |
$10,368.79
|
| Rate for Payer: Kentucky WC Medicaid |
$9,948.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,442.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,047.36
|
|
|
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC
|
Facility
|
IP
|
$8,550.22
|
|
|
Service Code
|
MSDRG 726
|
| Min. Negotiated Rate |
$5,801.94 |
| Max. Negotiated Rate |
$8,550.22 |
| Rate for Payer: Anthem Medicaid |
$5,801.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,107.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,550.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,244.86
|
| Rate for Payer: Humana KY Medicaid |
$5,801.94
|
| Rate for Payer: Humana Medicare Advantage |
$6,107.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,859.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,328.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,917.97
|
|
|
BENIGN SHAVE REMVL 1ST LESION
|
Professional
|
Both
|
$125.00
|
|
| Hospital Charge Code |
22200331
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
|
|
BENLYSTA 10MG [120MG VIAL]
|
Facility
|
OP
|
$3,391.54
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$3,255.88 |
| Rate for Payer: Anthem Medicaid |
$1,166.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,645.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$72.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.20
|
| Rate for Payer: Cash Price |
$1,695.77
|
| Rate for Payer: Cash Price |
$1,695.77
|
| Rate for Payer: Cigna Commercial |
$2,814.98
|
| Rate for Payer: First Health Commercial |
$3,221.96
|
| Rate for Payer: Humana Commercial |
$2,882.81
|
| Rate for Payer: Humana KY Medicaid |
$1,166.35
|
| Rate for Payer: Humana Medicare Advantage |
$52.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,178.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,781.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,502.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,189.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,984.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,543.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$678.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$440.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,051.38
|
| Rate for Payer: PHCS Commercial |
$3,255.88
|
| Rate for Payer: United Healthcare All Payer |
$2,984.56
|
| Rate for Payer: Aetna Commercial |
$2,611.49
|
|
|
BENLYSTA 10MG [120MG VIAL]
|
Facility
|
IP
|
$3,391.54
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$440.90 |
| Max. Negotiated Rate |
$3,255.88 |
| Rate for Payer: Aetna Commercial |
$2,611.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,645.40
|
| Rate for Payer: Cash Price |
$1,695.77
|
| Rate for Payer: Cigna Commercial |
$2,814.98
|
| Rate for Payer: First Health Commercial |
$3,221.96
|
| Rate for Payer: Humana Commercial |
$2,882.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,781.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,502.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,017.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,984.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,543.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$678.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$440.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,051.38
|
| Rate for Payer: PHCS Commercial |
$3,255.88
|
| Rate for Payer: United Healthcare All Payer |
$2,984.56
|
|
|
BENLYSTA 10 MG [400MG VIAL]
|
Facility
|
IP
|
$11,304.50
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,469.58 |
| Max. Negotiated Rate |
$10,852.32 |
| Rate for Payer: Aetna Commercial |
$8,704.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,817.51
|
| Rate for Payer: Cash Price |
$5,652.25
|
| Rate for Payer: Cigna Commercial |
$9,382.74
|
| Rate for Payer: First Health Commercial |
$10,739.28
|
| Rate for Payer: Humana Commercial |
$9,608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,269.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,342.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,391.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,947.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,478.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,260.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,469.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,504.40
|
| Rate for Payer: PHCS Commercial |
$10,852.32
|
| Rate for Payer: United Healthcare All Payer |
$9,947.96
|
|
|
BENLYSTA 10 MG [400MG VIAL]
|
Facility
|
OP
|
$11,304.50
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$10,852.32 |
| Rate for Payer: Aetna Commercial |
$8,704.46
|
| Rate for Payer: Anthem Medicaid |
$3,887.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,817.51
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$72.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.20
|
| Rate for Payer: Cash Price |
$5,652.25
|
| Rate for Payer: Cash Price |
$5,652.25
|
| Rate for Payer: Cigna Commercial |
$9,382.74
|
| Rate for Payer: First Health Commercial |
$10,739.28
|
| Rate for Payer: Humana Commercial |
$9,608.82
|
| Rate for Payer: Humana KY Medicaid |
$3,887.62
|
| Rate for Payer: Humana Medicare Advantage |
$52.00
|
| Rate for Payer: Kentucky WC Medicaid |
$3,927.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,269.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,342.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,965.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,947.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,478.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,260.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,469.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,504.40
|
| Rate for Payer: PHCS Commercial |
$10,852.32
|
| Rate for Payer: United Healthcare All Payer |
$9,947.96
|
|
|
BENTSON ST. WIRE 135CM
|
Facility
|
OP
|
$494.94
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$475.14 |
| Rate for Payer: Aetna Commercial |
$381.10
|
| Rate for Payer: Anthem Medicaid |
$170.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$386.05
|
| Rate for Payer: Cash Price |
$247.47
|
| Rate for Payer: Cigna Commercial |
$410.80
|
| Rate for Payer: First Health Commercial |
$470.19
|
| Rate for Payer: Humana Commercial |
$420.70
|
| Rate for Payer: Humana KY Medicaid |
$170.21
|
| Rate for Payer: Kentucky WC Medicaid |
$171.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$365.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$173.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$435.55
|
| Rate for Payer: Ohio Health Group HMO |
$371.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.43
|
| Rate for Payer: PHCS Commercial |
$475.14
|
| Rate for Payer: United Healthcare All Payer |
$435.55
|
|
|
BENTSON ST. WIRE 135CM
|
Facility
|
IP
|
$494.94
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$475.14 |
| Rate for Payer: Aetna Commercial |
$381.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$386.05
|
| Rate for Payer: Cash Price |
$247.47
|
| Rate for Payer: Cigna Commercial |
$410.80
|
| Rate for Payer: First Health Commercial |
$470.19
|
| Rate for Payer: Humana Commercial |
$420.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$365.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$435.55
|
| Rate for Payer: Ohio Health Group HMO |
$371.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.43
|
| Rate for Payer: PHCS Commercial |
$475.14
|
| Rate for Payer: United Healthcare All Payer |
$435.55
|
|
|
BENTYL (DICYCLOMINE) 10MG/1CAP
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
25000323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
BENTYL (DICYCLOMINE) 10MG/1CAP
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
25000323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
BENTYL(DICYCLOMINE) 1 10MG/5ML
|
Facility
|
OP
|
$9.20
|
|
|
Service Code
|
NDC 603116158
|
| Hospital Charge Code |
25000325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Anthem Medicaid |
$3.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.18
|
| Rate for Payer: Cash Price |
$4.60
|
| Rate for Payer: Cigna Commercial |
$7.64
|
| Rate for Payer: First Health Commercial |
$8.74
|
| Rate for Payer: Humana Commercial |
$7.82
|
| Rate for Payer: Humana KY Medicaid |
$3.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.10
|
| Rate for Payer: Ohio Health Group HMO |
$6.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.85
|
| Rate for Payer: PHCS Commercial |
$8.83
|
| Rate for Payer: United Healthcare All Payer |
$8.10
|
| Rate for Payer: Aetna Commercial |
$7.08
|
|
|
BENTYL(DICYCLOMINE) 1 10MG/5ML
|
Facility
|
IP
|
$9.20
|
|
|
Service Code
|
NDC 603116158
|
| Hospital Charge Code |
25000325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Aetna Commercial |
$7.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.18
|
| Rate for Payer: Cash Price |
$4.60
|
| Rate for Payer: Cigna Commercial |
$7.64
|
| Rate for Payer: First Health Commercial |
$8.74
|
| Rate for Payer: Humana Commercial |
$7.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.10
|
| Rate for Payer: Ohio Health Group HMO |
$6.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.85
|
| Rate for Payer: PHCS Commercial |
$8.83
|
| Rate for Payer: United Healthcare All Payer |
$8.10
|
|
|
BENTYL (DICYCLOMINE) 20MG/1TAB
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 60687038001
|
| Hospital Charge Code |
25000324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| 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 |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
BENTYL (DICYCLOMINE) 20MG/1TAB
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 60687038001
|
| Hospital Charge Code |
25000324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| 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 |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
BENTYL (DICYCLOMINE) 20MG/2ML
|
Facility
|
IP
|
$353.06
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
25001887
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$338.94 |
| Rate for Payer: Aetna Commercial |
$271.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$275.39
|
| Rate for Payer: Cash Price |
$176.53
|
| Rate for Payer: Cigna Commercial |
$293.04
|
| Rate for Payer: First Health Commercial |
$335.41
|
| Rate for Payer: Humana Commercial |
$300.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$289.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$260.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$310.69
|
| Rate for Payer: Ohio Health Group HMO |
$264.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.45
|
| Rate for Payer: PHCS Commercial |
$338.94
|
| Rate for Payer: United Healthcare All Payer |
$310.69
|
|
