|
AXLE RS OSS
|
Facility
|
OP
|
$4,513.59
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.08 |
| Max. Negotiated Rate |
$4,333.05 |
| Rate for Payer: Aetna Commercial |
$3,475.46
|
| Rate for Payer: Anthem Medicaid |
$1,552.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,520.60
|
| Rate for Payer: Cash Price |
$2,256.79
|
| Rate for Payer: Cigna Commercial |
$3,746.28
|
| Rate for Payer: First Health Commercial |
$4,287.91
|
| Rate for Payer: Humana Commercial |
$3,836.55
|
| Rate for Payer: Humana KY Medicaid |
$1,552.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,568.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,701.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,331.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,354.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,583.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,971.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,385.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,610.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,926.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,114.38
|
| Rate for Payer: PHCS Commercial |
$4,333.05
|
| Rate for Payer: United Healthcare All Payer |
$3,971.96
|
|
|
AXLE RS OSS
|
Facility
|
IP
|
$4,513.59
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,354.08 |
| Max. Negotiated Rate |
$4,333.05 |
| Rate for Payer: Aetna Commercial |
$3,475.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,520.60
|
| Rate for Payer: Cash Price |
$2,256.79
|
| Rate for Payer: Cigna Commercial |
$3,746.28
|
| Rate for Payer: First Health Commercial |
$4,287.91
|
| Rate for Payer: Humana Commercial |
$3,836.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,701.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,331.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,354.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,971.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,385.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,610.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,926.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,114.38
|
| Rate for Payer: PHCS Commercial |
$4,333.05
|
| Rate for Payer: United Healthcare All Payer |
$3,971.96
|
|
|
AXUMIN FLUCICLOVIN F18 1MCLX10
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
34000073
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$116.24 |
| Max. Negotiated Rate |
$375.79 |
| Rate for Payer: Aetna Commercial |
$260.26
|
| Rate for Payer: Anthem Medicaid |
$116.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$268.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$263.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$375.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$362.37
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cigna Commercial |
$280.54
|
| Rate for Payer: First Health Commercial |
$321.10
|
| Rate for Payer: Humana Commercial |
$287.30
|
| Rate for Payer: Humana KY Medicaid |
$116.24
|
| Rate for Payer: Humana Medicare Advantage |
$268.42
|
| Rate for Payer: Kentucky WC Medicaid |
$117.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$249.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$322.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$118.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$297.44
|
| Rate for Payer: Ohio Health Group HMO |
$253.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$270.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$233.22
|
| Rate for Payer: PHCS Commercial |
$324.48
|
| Rate for Payer: United Healthcare All Payer |
$297.44
|
|
|
AXUMIN FLUCICLOVIN F18 1MCLX10
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
34000073
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$324.48 |
| Rate for Payer: Aetna Commercial |
$260.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$263.64
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cigna Commercial |
$280.54
|
| Rate for Payer: First Health Commercial |
$321.10
|
| Rate for Payer: Humana Commercial |
$287.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$249.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$297.44
|
| Rate for Payer: Ohio Health Group HMO |
$253.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$270.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$233.22
|
| Rate for Payer: PHCS Commercial |
$324.48
|
| Rate for Payer: United Healthcare All Payer |
$297.44
|
|
|
AYGESTIN 5MG TABLET
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
25000299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| 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: 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: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
AYGESTIN 5MG TABLET
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
25000299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| 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 |
$3.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
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 |
$5.17 |
| 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 |
$5.17
|
| 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 |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.90
|
| Rate for Payer: PHCS Commercial |
$16.56
|
| Rate for Payer: United Healthcare All Payer |
$15.18
|
|
|
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 |
$5.17 |
| 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 |
$5.17
|
| 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 |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.90
|
| Rate for Payer: PHCS Commercial |
$16.56
|
| Rate for Payer: United Healthcare All Payer |
$15.18
|
|
|
AZILECT 1MG TAB
|
Facility
|
IP
|
$23.87
|
|
|
Service Code
|
NDC 93306156
|
| Hospital Charge Code |
25000301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.16 |
| 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 |
$19.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.47
|
| Rate for Payer: PHCS Commercial |
$22.92
|
| Rate for Payer: United Healthcare All Payer |
$21.01
|
|
|
AZILECT 1MG TAB
|
Facility
|
OP
|
$23.87
|
|
|
Service Code
|
NDC 93306156
|
| Hospital Charge Code |
25000301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$22.92 |
| 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
|
| 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 |
$19.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.47
|
| Rate for Payer: PHCS Commercial |
$22.92
|
| Rate for Payer: United Healthcare All Payer |
$21.01
|
|
|
AZOPT 1%OPHTH(BRINZOLAMIDE)5ML
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 68682046410
|
| Hospital Charge Code |
25000302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
AZOPT 1%OPHTH(BRINZOLAMIDE)5ML
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 68682046410
|
| Hospital Charge Code |
25000302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
Aztreonam 100mg (1gm IM)
|
Facility
|
OP
|
$192.08
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.62 |
| Max. Negotiated Rate |
$184.40 |
| Rate for Payer: Aetna Commercial |
$147.90
|
| Rate for Payer: Anthem Medicaid |
$66.06
|
| 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: Humana KY Medicaid |
$66.06
|
| 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 |
$57.62
|
| 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 |
$153.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.54
|
| Rate for Payer: PHCS Commercial |
$184.40
|
| Rate for Payer: United Healthcare All Payer |
$169.03
|
|
|
Aztreonam 100mg (1gm IM)
|
Facility
|
IP
|
$192.08
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.62 |
| 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 |
$153.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.54
|
| 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 |
$57.62 |
| 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 |
$153.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.54
|
| 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 |
$57.62 |
| Max. Negotiated Rate |
$184.40 |
| Rate for Payer: Aetna Commercial |
$147.90
|
| Rate for Payer: Anthem Medicaid |
$66.06
|
| 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: Humana KY Medicaid |
$66.06
|
| 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 |
$57.62
|
| 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 |
$153.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.54
|
| Rate for Payer: PHCS Commercial |
$184.40
|
| Rate for Payer: United Healthcare All Payer |
$169.03
|
|
|
Aztreonam 100mg (2m Syr)
|
Facility
|
OP
|
$342.31
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.69 |
| Max. Negotiated Rate |
$328.62 |
| Rate for Payer: Aetna Commercial |
$263.58
|
| Rate for Payer: Anthem Medicaid |
$117.72
|
| 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: Humana KY Medicaid |
$117.72
|
| 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 |
$102.69
|
| 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 |
$273.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$297.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.19
|
| Rate for Payer: PHCS Commercial |
$328.62
|
| Rate for Payer: United Healthcare All Payer |
$301.23
|
|
|
Aztreonam 100mg (2m Syr)
|
Facility
|
IP
|
$342.31
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
25003803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.69 |
| 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 |
$273.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$297.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.19
|
| Rate for Payer: PHCS Commercial |
$328.62
|
| Rate for Payer: United Healthcare All Payer |
$301.23
|
|
|
AZULFIDINE(SULFASAL 500MG/1TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 93323401
|
| Hospital Charge Code |
25000303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
AZULFIDINE(SULFASAL 500MG/1TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 93323401
|
| Hospital Charge Code |
25000303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
BABESIA MICROTI AMP PRB
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS 87469
|
| Hospital Charge Code |
30002061
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$52.20 |
| Max. Negotiated Rate |
$167.04 |
| Rate for Payer: Aetna Commercial |
$133.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.72
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$144.42
|
| Rate for Payer: First Health Commercial |
$165.30
|
| Rate for Payer: Humana Commercial |
$147.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$142.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$128.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$153.12
|
| Rate for Payer: Ohio Health Group HMO |
$130.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.06
|
| Rate for Payer: PHCS Commercial |
$167.04
|
| Rate for Payer: United Healthcare All Payer |
$153.12
|
|
|
BABESIA MICROTI AMP PRB
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS 87469
|
| Hospital Charge Code |
30002061
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$167.04 |
| Rate for Payer: Aetna Commercial |
$133.98
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$144.42
|
| Rate for Payer: First Health Commercial |
$165.30
|
| Rate for Payer: Humana Commercial |
$147.90
|
| 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 |
$142.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$128.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$153.12
|
| Rate for Payer: Ohio Health Group HMO |
$130.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.06
|
| Rate for Payer: PHCS Commercial |
$167.04
|
| Rate for Payer: United Healthcare All Payer |
$153.12
|
|
|
BABYGRAM
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
32000182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$114.60 |
| Max. Negotiated Rate |
$366.72 |
| Rate for Payer: Aetna Commercial |
$294.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.96
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$317.06
|
| Rate for Payer: First Health Commercial |
$362.90
|
| Rate for Payer: Humana Commercial |
$324.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$313.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$336.16
|
| Rate for Payer: Ohio Health Group HMO |
$286.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$332.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.58
|
| Rate for Payer: PHCS Commercial |
$366.72
|
| Rate for Payer: United Healthcare All Payer |
$336.16
|
|
|
BABYGRAM
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
32000182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$229.20 |
| Rate for Payer: Aetna Commercial |
$42.50
|
| Rate for Payer: Ambetter Exchange |
$26.53
|
| Rate for Payer: Anthem Medicaid |
$21.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.84
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$42.59
|
| Rate for Payer: Healthspan PPO |
$39.83
|
| Rate for Payer: Humana Medicaid |
$21.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.25
|
| Rate for Payer: Molina Healthcare Passport |
$21.81
|
| Rate for Payer: Multiplan PHCS |
$229.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.49
|
| Rate for Payer: UHCCP Medicaid |
$133.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.53
|
|
|
BABYGRAM
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
HCPCS 76010
|
| Hospital Charge Code |
32000182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$366.72 |
| Rate for Payer: Aetna Commercial |
$294.14
|
| Rate for Payer: Anthem Medicaid |
$131.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$317.06
|
| Rate for Payer: First Health Commercial |
$362.90
|
| Rate for Payer: Humana Commercial |
$324.70
|
| Rate for Payer: Humana KY Medicaid |
$131.37
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$132.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$313.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$134.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$336.16
|
| Rate for Payer: Ohio Health Group HMO |
$286.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$332.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.58
|
| Rate for Payer: PHCS Commercial |
$366.72
|
| Rate for Payer: United Healthcare All Payer |
$336.16
|
|
