|
TESTOSTERONE (TOTAL)
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000522
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$236.16 |
| Rate for Payer: Aetna Commercial |
$189.42
|
| Rate for Payer: Anthem Medicaid |
$84.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$197.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.81
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$204.18
|
| Rate for Payer: First Health Commercial |
$233.70
|
| Rate for Payer: Humana Commercial |
$209.10
|
| Rate for Payer: Humana KY Medicaid |
$84.60
|
| Rate for Payer: Humana Medicare Advantage |
$25.81
|
| Rate for Payer: Kentucky WC Medicaid |
$85.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$201.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$181.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$86.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$216.48
|
| Rate for Payer: Ohio Health Group HMO |
$184.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.26
|
| Rate for Payer: PHCS Commercial |
$236.16
|
| Rate for Payer: United Healthcare All Payer |
$216.48
|
|
|
TESTOSTERONE (TOTAL)
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000522
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$236.16 |
| Rate for Payer: Aetna Commercial |
$189.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$197.54
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$204.18
|
| Rate for Payer: First Health Commercial |
$233.70
|
| Rate for Payer: Humana Commercial |
$209.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$201.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$181.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$216.48
|
| Rate for Payer: Ohio Health Group HMO |
$184.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.26
|
| Rate for Payer: PHCS Commercial |
$236.16
|
| Rate for Payer: United Healthcare All Payer |
$216.48
|
|
|
TESTOSTERONE (TOTAL)
|
Professional
|
Both
|
$246.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000522
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.34 |
| Max. Negotiated Rate |
$246.00 |
| Rate for Payer: Aetna Commercial |
$47.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$246.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$22.78
|
| Rate for Payer: Healthspan PPO |
$21.34
|
| Rate for Payer: Multiplan PHCS |
$147.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$172.20
|
| Rate for Payer: UHCCP Medicaid |
$86.10
|
|
|
TETANUS & DIPHTHERIA +>7YRS
|
Facility
|
OP
|
$191.60
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$183.94 |
| Rate for Payer: Aetna Commercial |
$147.53
|
| Rate for Payer: Anthem Medicaid |
$65.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.45
|
| Rate for Payer: Cash Price |
$95.80
|
| Rate for Payer: Cigna Commercial |
$159.03
|
| Rate for Payer: First Health Commercial |
$182.02
|
| Rate for Payer: Humana Commercial |
$162.86
|
| Rate for Payer: Humana KY Medicaid |
$65.89
|
| Rate for Payer: Kentucky WC Medicaid |
$66.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.61
|
| Rate for Payer: Ohio Health Group HMO |
$143.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.40
|
| Rate for Payer: PHCS Commercial |
$183.94
|
| Rate for Payer: United Healthcare All Payer |
$168.61
|
|
|
TETANUS & DIPHTHERIA +>7YRS
|
Facility
|
IP
|
$191.60
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$183.94 |
| Rate for Payer: Aetna Commercial |
$147.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.45
|
| Rate for Payer: Cash Price |
$95.80
|
| Rate for Payer: Cigna Commercial |
$159.03
|
| Rate for Payer: First Health Commercial |
$182.02
|
| Rate for Payer: Humana Commercial |
$162.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.61
|
| Rate for Payer: Ohio Health Group HMO |
$143.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.40
|
| Rate for Payer: PHCS Commercial |
$183.94
|
| Rate for Payer: United Healthcare All Payer |
$168.61
|
|
|
TETANUS+DIPH TOX,ADLT 0.5mL VL
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25004096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.70 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.20
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: First Health Commercial |
$180.50
|
| Rate for Payer: Humana Commercial |
$161.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.20
|
| Rate for Payer: Ohio Health Group HMO |
$142.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.90
|
| Rate for Payer: PHCS Commercial |
$182.40
|
| Rate for Payer: United Healthcare All Payer |
$167.20
|
|
|
TETANUS+DIPH TOX,ADLT 0.5mL VL
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25004096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.70 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Anthem Medicaid |
$65.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.20
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: First Health Commercial |
$180.50
|
| Rate for Payer: Humana Commercial |
$161.50
|
| Rate for Payer: Humana KY Medicaid |
$65.34
|
| Rate for Payer: Kentucky WC Medicaid |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.20
|
| Rate for Payer: Ohio Health Group HMO |
$142.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.90
|
| Rate for Payer: PHCS Commercial |
$182.40
|
| Rate for Payer: United Healthcare All Payer |
$167.20
|
|
|
TETRABENAZINE 12.5mg TABLET
|
Facility
|
OP
|
$9.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna Commercial |
$7.19
|
| Rate for Payer: Anthem Medicaid |
$3.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.29
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna Commercial |
$7.75
|
| Rate for Payer: First Health Commercial |
$8.87
|
| Rate for Payer: Humana Commercial |
$7.94
|
| Rate for Payer: Humana KY Medicaid |
$3.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.22
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$8.97
|
| Rate for Payer: United Healthcare All Payer |
$8.22
|
|
|
TETRABENAZINE 12.5mg TABLET
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna Commercial |
$7.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.29
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna Commercial |
$7.75
|
| Rate for Payer: First Health Commercial |
$8.87
|
| Rate for Payer: Humana Commercial |
$7.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.22
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$8.97
|
| Rate for Payer: United Healthcare All Payer |
$8.22
|
|
|
TETRABENAZINE 25mg TABLET
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem Medicaid |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.15
|
| Rate for Payer: Humana Commercial |
$9.08
|
| Rate for Payer: Humana KY Medicaid |
$3.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.40
|
| Rate for Payer: Ohio Health Group HMO |
$8.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$10.25
|
| Rate for Payer: United Healthcare All Payer |
$9.40
|
|
|
TETRABENAZINE 25mg TABLET
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.15
|
| Rate for Payer: Humana Commercial |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.40
|
| Rate for Payer: Ohio Health Group HMO |
$8.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$10.25
|
| Rate for Payer: United Healthcare All Payer |
$9.40
|
|
|
TETRACAINE 0.5% 5mL EYE DROPS
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TETRACAINE 0.5% 5mL EYE DROPS
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TETRACAINE OPHT SOL .5% EA GTT
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 68682092064
|
| Hospital Charge Code |
25003519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TETRACAINE OPHT SOL .5% EA GTT
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 68682092064
|
| Hospital Charge Code |
25003519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TETRACAINE/PF 0.5% PER DROP
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
NDC 65074114
|
| Hospital Charge Code |
25003518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
TETRACAINE/PF 0.5% PER DROP
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
NDC 65074114
|
| Hospital Charge Code |
25003518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
TETRACYCLINE 250 MG 250MG/1CAP
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
NDC 51991090601
|
| Hospital Charge Code |
25001513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
TETRACYCLINE 250 MG 250MG/1CAP
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 51991090601
|
| Hospital Charge Code |
25001513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
TETRACYCLINE 500 MG CAPSULE
|
Facility
|
OP
|
$11.29
|
|
|
Service Code
|
NDC 51991090701
|
| Hospital Charge Code |
25001514
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$8.69
|
| Rate for Payer: Anthem Medicaid |
$3.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.81
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cigna Commercial |
$9.37
|
| Rate for Payer: First Health Commercial |
$10.73
|
| Rate for Payer: Humana Commercial |
$9.60
|
| Rate for Payer: Humana KY Medicaid |
$3.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.94
|
| Rate for Payer: Ohio Health Group HMO |
$8.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.50
|
| Rate for Payer: PHCS Commercial |
$10.84
|
| Rate for Payer: United Healthcare All Payer |
$9.94
|
|
|
TETRACYCLINE 500 MG CAPSULE
|
Facility
|
IP
|
$11.29
|
|
|
Service Code
|
NDC 51991090701
|
| Hospital Charge Code |
25001514
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$8.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.81
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cigna Commercial |
$9.37
|
| Rate for Payer: First Health Commercial |
$10.73
|
| Rate for Payer: Humana Commercial |
$9.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.94
|
| Rate for Payer: Ohio Health Group HMO |
$8.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.50
|
| Rate for Payer: PHCS Commercial |
$10.84
|
| Rate for Payer: United Healthcare All Payer |
$9.94
|
|
|
TEVETEN 600MG TABLET
|
Facility
|
OP
|
$10.74
|
|
|
Service Code
|
NDC 378662993
|
| Hospital Charge Code |
25001516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Aetna Commercial |
$8.27
|
| Rate for Payer: Anthem Medicaid |
$3.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cigna Commercial |
$8.91
|
| Rate for Payer: First Health Commercial |
$10.20
|
| Rate for Payer: Humana Commercial |
$9.13
|
| Rate for Payer: Humana KY Medicaid |
$3.69
|
| Rate for Payer: Kentucky WC Medicaid |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.45
|
| Rate for Payer: Ohio Health Group HMO |
$8.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$10.31
|
| Rate for Payer: United Healthcare All Payer |
$9.45
|
|
|
TEVETEN 600MG TABLET
|
Facility
|
IP
|
$10.74
|
|
|
Service Code
|
NDC 378662993
|
| Hospital Charge Code |
25001516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Aetna Commercial |
$8.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cigna Commercial |
$8.91
|
| Rate for Payer: First Health Commercial |
$10.20
|
| Rate for Payer: Humana Commercial |
$9.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.45
|
| Rate for Payer: Ohio Health Group HMO |
$8.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$10.31
|
| Rate for Payer: United Healthcare All Payer |
$9.45
|
|
|
TEXAS CATHETER MED INTERCON
|
Facility
|
IP
|
$26.47
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.65
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cigna Commercial |
$21.97
|
| Rate for Payer: First Health Commercial |
$25.15
|
| Rate for Payer: Humana Commercial |
$22.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.29
|
| Rate for Payer: Ohio Health Group HMO |
$19.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.21
|
| Rate for Payer: PHCS Commercial |
$25.41
|
| Rate for Payer: United Healthcare All Payer |
$23.29
|
|
|
TEXAS CATHETER MED INTERCON
|
Facility
|
OP
|
$26.47
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Anthem Medicaid |
$9.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.65
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cigna Commercial |
$21.97
|
| Rate for Payer: First Health Commercial |
$25.15
|
| Rate for Payer: Humana Commercial |
$22.50
|
| Rate for Payer: Humana KY Medicaid |
$9.10
|
| Rate for Payer: Kentucky WC Medicaid |
$9.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.29
|
| Rate for Payer: Ohio Health Group HMO |
$19.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.21
|
| Rate for Payer: PHCS Commercial |
$25.41
|
| Rate for Payer: United Healthcare All Payer |
$23.29
|
|
