|
AUDIT/DAST OVER 30 MIN
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
51000111
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$153.60 |
| Rate for Payer: Aetna Commercial |
$123.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.80
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: First Health Commercial |
$152.00
|
| Rate for Payer: Humana Commercial |
$136.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.80
|
| Rate for Payer: Ohio Health Group HMO |
$120.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.40
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
AUDIT/DAST OVER 30 MIN(P
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
510P0111
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$100.74
|
| Rate for Payer: Anthem Medicaid |
$53.20
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$87.77
|
| Rate for Payer: Healthspan PPO |
$80.34
|
| Rate for Payer: Humana Medicaid |
$53.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.26
|
| Rate for Payer: Molina Healthcare Passport |
$53.20
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.73
|
|
|
AUGMENT 25062.5MG/5ML EQ100ML
|
Facility
|
OP
|
$11.45
|
|
|
Service Code
|
NDC 59651002675
|
| Hospital Charge Code |
25002861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Anthem Medicaid |
$3.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.93
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: First Health Commercial |
$10.88
|
| Rate for Payer: Humana Commercial |
$9.73
|
| Rate for Payer: Humana KY Medicaid |
$3.94
|
| Rate for Payer: Kentucky WC Medicaid |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.45
|
| 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 |
$8.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.90
|
| Rate for Payer: PHCS Commercial |
$10.99
|
| Rate for Payer: United Healthcare All Payer |
$10.08
|
|
|
AUGMENT 25062.5MG/5ML EQ100ML
|
Facility
|
IP
|
$11.45
|
|
|
Service Code
|
NDC 59651002675
|
| Hospital Charge Code |
25002861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.93
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: First Health Commercial |
$10.88
|
| Rate for Payer: Humana Commercial |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.08
|
| Rate for Payer: Ohio Health Group HMO |
$8.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.90
|
| Rate for Payer: PHCS Commercial |
$10.99
|
| 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 |
$2,389.07 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem Medicaid |
$2,389.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| 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 |
$5,465.95
|
| 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 |
$6,559.14
|
| 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 |
$5,557.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,043.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,793.43
|
| 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 |
$2,084.10 |
| 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 |
$5,557.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,043.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,793.43
|
| 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 |
$2,389.07 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem Medicaid |
$2,389.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| 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 |
$5,465.95
|
| 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 |
$6,559.14
|
| 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 |
$5,557.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,043.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,793.43
|
| 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 |
$2,084.10 |
| 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 |
$5,557.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,043.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,793.43
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
AUGMENTATIVE EVAL 1ST HR
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS 92605
|
| Hospital Charge Code |
44000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$161.10 |
| Max. Negotiated Rate |
$515.52 |
| Rate for Payer: Aetna Commercial |
$413.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$418.86
|
| Rate for Payer: Cash Price |
$268.50
|
| Rate for Payer: Cigna Commercial |
$445.71
|
| Rate for Payer: First Health Commercial |
$510.15
|
| Rate for Payer: Humana Commercial |
$456.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$440.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$396.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$472.56
|
| Rate for Payer: Ohio Health Group HMO |
$402.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$429.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$467.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$370.53
|
| Rate for Payer: PHCS Commercial |
$515.52
|
| Rate for Payer: United Healthcare All Payer |
$472.56
|
|
|
AUGMENTATIVE EVAL 1ST HR
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS 92605
|
| Hospital Charge Code |
44000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$161.10 |
| Max. Negotiated Rate |
$515.52 |
| Rate for Payer: Aetna Commercial |
$413.49
|
| Rate for Payer: Anthem Medicaid |
$184.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$418.86
|
| Rate for Payer: Cash Price |
$268.50
|
| Rate for Payer: Cigna Commercial |
$445.71
|
| Rate for Payer: First Health Commercial |
$510.15
|
| Rate for Payer: Humana Commercial |
$456.45
|
| Rate for Payer: Humana KY Medicaid |
$184.67
|
| Rate for Payer: Kentucky WC Medicaid |
$186.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$440.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$396.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$188.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$472.56
|
| Rate for Payer: Ohio Health Group HMO |
$402.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$429.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$467.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$370.53
|
| Rate for Payer: PHCS Commercial |
$515.52
|
| Rate for Payer: United Healthcare All Payer |
$472.56
|
|
|
AUGMENTATIVE EVAL EA AD30 MIN
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 92618
|
| Hospital Charge Code |
44000015
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| 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 |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
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 |
$1.52 |
| 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 |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
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 |
$1.52 |
| 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 |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
AUGMENTIN 600MG/5ML SUSPENSION
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 781613948
|
| Hospital Charge Code |
25000286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
AUGMENTIN 600MG/5ML SUSPENSION
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 781613948
|
| Hospital Charge Code |
25000286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| 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 |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| 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 |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
AUGMENTIN (AMOX/CLAV) 500MG/1T
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 65862050220
|
| Hospital Charge Code |
25002859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
AUGMENTIN (AMOX/CLAV) 500MG/1T
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 65862050220
|
| Hospital Charge Code |
25002859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
AUGMENTIN (AMOX/CLV) 875MG/1T)
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25002860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
AUGMENTIN (AMOX/CLV) 875MG/1T)
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25002860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
AUGMENTIN EQ 400MG/5ML SUSP
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 143998275
|
| Hospital Charge Code |
25002862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.43
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
AUGMENTIN EQ 400MG/5ML SUSP
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 143998275
|
| Hospital Charge Code |
25002862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.43
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 L
|
Facility
|
IP
|
$11,133.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,340.08 |
| Max. Negotiated Rate |
$10,688.26 |
| Rate for Payer: Aetna Commercial |
$8,572.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,684.21
|
| Rate for Payer: Cash Price |
$5,566.80
|
| Rate for Payer: Cigna Commercial |
$9,240.89
|
| Rate for Payer: First Health Commercial |
$10,576.92
|
| Rate for Payer: Humana Commercial |
$9,463.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,129.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,216.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,340.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,797.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,350.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,906.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,686.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,682.18
|
| Rate for Payer: PHCS Commercial |
$10,688.26
|
| Rate for Payer: United Healthcare All Payer |
$9,797.57
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 L
|
Facility
|
OP
|
$11,133.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,340.08 |
| Max. Negotiated Rate |
$10,688.26 |
| Rate for Payer: Aetna Commercial |
$8,572.87
|
| Rate for Payer: Anthem Medicaid |
$3,828.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,684.21
|
| Rate for Payer: Cash Price |
$5,566.80
|
| Rate for Payer: Cigna Commercial |
$9,240.89
|
| Rate for Payer: First Health Commercial |
$10,576.92
|
| Rate for Payer: Humana Commercial |
$9,463.56
|
| Rate for Payer: Humana KY Medicaid |
$3,828.85
|
| Rate for Payer: Kentucky WC Medicaid |
$3,867.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,129.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,216.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,340.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,905.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,797.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,350.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,906.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,686.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,682.18
|
| Rate for Payer: PHCS Commercial |
$10,688.26
|
| Rate for Payer: United Healthcare All Payer |
$9,797.57
|
|
|
AUGMENT LEGION UNIVERSAL SZ4 R
|
Facility
|
IP
|
$11,133.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,340.08 |
| Max. Negotiated Rate |
$10,688.26 |
| Rate for Payer: Aetna Commercial |
$8,572.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,684.21
|
| Rate for Payer: Cash Price |
$5,566.80
|
| Rate for Payer: Cigna Commercial |
$9,240.89
|
| Rate for Payer: First Health Commercial |
$10,576.92
|
| Rate for Payer: Humana Commercial |
$9,463.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,129.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,216.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,340.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,797.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,350.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,906.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,686.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,682.18
|
| Rate for Payer: PHCS Commercial |
$10,688.26
|
| Rate for Payer: United Healthcare All Payer |
$9,797.57
|
|
