|
BETAPACE (SOTALOL HCL) 120MG T
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 50268072515
|
| Hospital Charge Code |
25000331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
BETAPACE (SOTALOL HCL) 120MG T
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 50268072515
|
| Hospital Charge Code |
25000331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
BETA SUB QUALITATIVE HC6 URINE
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS 81025
|
| Hospital Charge Code |
30000179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem Medicaid |
$8.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.61
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Humana KY Medicaid |
$8.61
|
| Rate for Payer: Humana Medicare Advantage |
$8.61
|
| Rate for Payer: Kentucky WC Medicaid |
$8.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.33
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
BETA SUB QUALITATIVE HC6 URINE
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS 81025
|
| Hospital Charge Code |
30000179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$43.00
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$8.82
|
| Rate for Payer: Healthspan PPO |
$6.63
|
| Rate for Payer: Multiplan PHCS |
$25.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.10
|
| Rate for Payer: UHCCP Medicaid |
$15.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.17
|
|
|
BETA SUB QUALITATIVE HC6 URINE
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS 81025
|
| Hospital Charge Code |
30000179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34.53
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.33
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
BETAXOLOL 20MG TABLET
|
Facility
|
IP
|
$9.32
|
|
|
Service Code
|
NDC 10702001401
|
| Hospital Charge Code |
25000335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.95 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.27
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.85
|
| Rate for Payer: Humana Commercial |
$7.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.20
|
| Rate for Payer: Ohio Health Group HMO |
$6.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.95
|
| Rate for Payer: United Healthcare All Payer |
$8.20
|
|
|
BETAXOLOL 20MG TABLET
|
Facility
|
OP
|
$9.32
|
|
|
Service Code
|
NDC 10702001401
|
| Hospital Charge Code |
25000335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.95 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem Medicaid |
$3.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.27
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.85
|
| Rate for Payer: Humana Commercial |
$7.92
|
| Rate for Payer: Humana KY Medicaid |
$3.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.20
|
| Rate for Payer: Ohio Health Group HMO |
$6.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.95
|
| Rate for Payer: United Healthcare All Payer |
$8.20
|
|
|
BETOPTIC (BETAXOLOL)0.5% O 5ML
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 61314024501
|
| Hospital Charge Code |
25000333
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.23
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna Commercial |
$2.37
|
| Rate for Payer: First Health Commercial |
$2.72
|
| Rate for Payer: Humana Commercial |
$2.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.52
|
| Rate for Payer: Ohio Health Group HMO |
$2.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.89
|
| Rate for Payer: PHCS Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Payer |
$2.52
|
|
|
BETOPTIC (BETAXOLOL)0.5% O 5ML
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 61314024501
|
| Hospital Charge Code |
25000333
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna Commercial |
$2.20
|
| Rate for Payer: Anthem Medicaid |
$0.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.23
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna Commercial |
$2.37
|
| Rate for Payer: First Health Commercial |
$2.72
|
| Rate for Payer: Humana Commercial |
$2.43
|
| Rate for Payer: Humana KY Medicaid |
$0.98
|
| Rate for Payer: Kentucky WC Medicaid |
$0.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.52
|
| Rate for Payer: Ohio Health Group HMO |
$2.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.89
|
| Rate for Payer: PHCS Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Payer |
$2.52
|
|
|
BETOPTIC (BETAXOLOL) OPHT 10ML
|
Facility
|
IP
|
$4.71
|
|
|
Service Code
|
NDC 10135062301
|
| Hospital Charge Code |
25003805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.91
|
| Rate for Payer: First Health Commercial |
$4.47
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.52
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
BETOPTIC (BETAXOLOL) OPHT 10ML
|
Facility
|
OP
|
$4.71
|
|
|
Service Code
|
NDC 10135062301
|
| Hospital Charge Code |
25003805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.91
|
| Rate for Payer: First Health Commercial |
$4.47
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.52
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
BETOPTIC S(BETAXOLOL) OPHT 5ML
|
Facility
|
IP
|
$4.87
|
|
|
Service Code
|
NDC 78072910
|
| Hospital Charge Code |
25000334
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
|
|
BETOPTIC S(BETAXOLOL) OPHT 5ML
|
Facility
|
OP
|
$4.87
|
|
|
Service Code
|
NDC 78072910
|
| Hospital Charge Code |
25000334
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
BEYFORTUS100MG/MLSDV
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
77000095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem Medicaid |
$363.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Humana KY Medicaid |
$363.50
|
| Rate for Payer: Kentucky WC Medicaid |
$367.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS100MG/MLSDV
|
Professional
|
Both
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
77000095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$369.95 |
| Max. Negotiated Rate |
$1,057.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,057.00
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Multiplan PHCS |
$634.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$739.90
|
| Rate for Payer: UHCCP Medicaid |
$369.95
|
|
|
BEYFORTUS100MG/MLSDV
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
770T0095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem Medicaid |
$363.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Humana KY Medicaid |
$363.50
|
| Rate for Payer: Kentucky WC Medicaid |
$367.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS100MG/MLSDV
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
77000095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS100MG/MLSDV
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90381
|
| Hospital Charge Code |
770T0095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
770T0096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
77000096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
77000096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem Medicaid |
$363.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Humana KY Medicaid |
$363.50
|
| Rate for Payer: Kentucky WC Medicaid |
$367.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Professional
|
Both
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
77000096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$369.95 |
| Max. Negotiated Rate |
$1,057.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,057.00
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Multiplan PHCS |
$634.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$739.90
|
| Rate for Payer: UHCCP Medicaid |
$369.95
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
770T0096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem Medicaid |
$363.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Humana KY Medicaid |
$363.50
|
| Rate for Payer: Kentucky WC Medicaid |
$367.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.67
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BF 40MM KLD GLENOD W/46MM SURF
|
Facility
|
IP
|
$9,159.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.77 |
| Max. Negotiated Rate |
$8,793.37 |
| Rate for Payer: Aetna Commercial |
$7,053.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,144.61
|
| Rate for Payer: Cash Price |
$4,579.88
|
| Rate for Payer: Cigna Commercial |
$7,602.60
|
| Rate for Payer: First Health Commercial |
$8,701.77
|
| Rate for Payer: Humana Commercial |
$7,785.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,511.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,759.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,747.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,060.59
|
| Rate for Payer: Ohio Health Group HMO |
$6,869.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,831.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,190.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,839.53
|
| Rate for Payer: PHCS Commercial |
$8,793.37
|
| Rate for Payer: United Healthcare All Payer |
$8,060.59
|
|
|
BF 40MM KLD GLENOD W/46MM SURF
|
Facility
|
OP
|
$9,159.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.77 |
| Max. Negotiated Rate |
$8,793.37 |
| Rate for Payer: Aetna Commercial |
$7,053.02
|
| Rate for Payer: Anthem Medicaid |
$3,150.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,144.61
|
| Rate for Payer: Cash Price |
$4,579.88
|
| Rate for Payer: Cigna Commercial |
$7,602.60
|
| Rate for Payer: First Health Commercial |
$8,701.77
|
| Rate for Payer: Humana Commercial |
$7,785.80
|
| Rate for Payer: Humana KY Medicaid |
$3,150.04
|
| Rate for Payer: Kentucky WC Medicaid |
$3,182.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,511.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,759.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,747.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,213.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,060.59
|
| Rate for Payer: Ohio Health Group HMO |
$6,869.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,831.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,190.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,839.53
|
| Rate for Payer: PHCS Commercial |
$8,793.37
|
| Rate for Payer: United Healthcare All Payer |
$8,060.59
|
|
