|
BENICAR(OLMESARTAN)20MG TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 68462043730
|
| Hospital Charge Code |
25000322
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
BENICAR (OLMESARTAN) 40 MG TAB
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 378712493
|
| Hospital Charge Code |
25000320
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
BENICAR (OLMESARTAN) 40 MG TAB
|
Facility
|
IP
|
$4.54
|
|
|
Service Code
|
NDC 378712493
|
| Hospital Charge Code |
25000320
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
BENIGN DESTRCTN 31-40 LESIONS
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200357
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
BENIGN DESTRCTN 31-40 LESIONS
|
Facility
|
IP
|
$250.00
|
|
| Hospital Charge Code |
22200357
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
BENIGN DESTRCTN 31-40 LESIONS
|
Facility
|
OP
|
$250.00
|
|
| Hospital Charge Code |
22200357
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem Medicaid |
$85.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Humana KY Medicaid |
$85.97
|
| Rate for Payer: Kentucky WC Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
BENIGN DESTRCTN 41-50 LESIONS
|
Facility
|
OP
|
$325.00
|
|
| Hospital Charge Code |
22200356
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem Medicaid |
$111.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Humana KY Medicaid |
$111.77
|
| Rate for Payer: Kentucky WC Medicaid |
$112.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
BENIGN DESTRCTN 41-50 LESIONS
|
Professional
|
Both
|
$325.00
|
|
| Hospital Charge Code |
22200356
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$227.50 |
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
|
|
BENIGN DESTRCTN 41-50 LESIONS
|
Facility
|
IP
|
$325.00
|
|
| Hospital Charge Code |
22200356
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
BENIGN DESTRUCTION 51+ LESIONS
|
Facility
|
OP
|
$400.00
|
|
| Hospital Charge Code |
22200355
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
BENIGN DESTRUCTION 51+ LESIONS
|
Facility
|
IP
|
$400.00
|
|
| Hospital Charge Code |
22200355
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
BENIGN DESTRUCTION 51+ LESIONS
|
Professional
|
Both
|
$400.00
|
|
| Hospital Charge Code |
22200355
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
BENIGN DESTRUCTN 1-10 LESIONS
|
Professional
|
Both
|
$125.00
|
|
| Hospital Charge Code |
22200328
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
|
|
BENIGN DESTRUCTN 11-20 LESIONS
|
Professional
|
Both
|
$175.00
|
|
| Hospital Charge Code |
22200329
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$122.50 |
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
|
|
BENIGN DESTRUCTN 21+ LESIONS
|
Professional
|
Both
|
$200.00
|
|
| Hospital Charge Code |
22200330
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
|
BENIGN SHAVE REMVL 1ST LESION
|
Professional
|
Both
|
$125.00
|
|
| Hospital Charge Code |
22200331
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
|
|
BENLYSTA 10MG [120MG VIAL]
|
Facility
|
OP
|
$3,459.39
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.01 |
| Max. Negotiated Rate |
$3,321.01 |
| Rate for Payer: Aetna Commercial |
$2,663.73
|
| Rate for Payer: Anthem Medicaid |
$1,189.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$56.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,698.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.61
|
| Rate for Payer: Cash Price |
$1,729.69
|
| Rate for Payer: Cash Price |
$1,729.69
|
| Rate for Payer: Cigna Commercial |
$2,871.29
|
| Rate for Payer: First Health Commercial |
$3,286.42
|
| Rate for Payer: Humana Commercial |
$2,940.48
|
| Rate for Payer: Humana KY Medicaid |
$1,189.68
|
| Rate for Payer: Humana Medicare Advantage |
$56.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,201.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,836.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,553.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,213.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,044.26
|
| Rate for Payer: Ohio Health Group HMO |
$2,594.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,767.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,009.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,386.98
|
| Rate for Payer: PHCS Commercial |
$3,321.01
|
| Rate for Payer: United Healthcare All Payer |
$3,044.26
|
|
|
BENLYSTA 10MG [120MG VIAL]
|
Facility
|
IP
|
$3,459.39
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,037.82 |
| Max. Negotiated Rate |
$3,321.01 |
| Rate for Payer: Aetna Commercial |
$2,663.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,698.32
|
| Rate for Payer: Cash Price |
$1,729.69
|
| Rate for Payer: Cigna Commercial |
$2,871.29
|
| Rate for Payer: First Health Commercial |
$3,286.42
|
| Rate for Payer: Humana Commercial |
$2,940.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,836.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,553.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,037.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,044.26
|
| Rate for Payer: Ohio Health Group HMO |
$2,594.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,767.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,009.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,386.98
|
| Rate for Payer: PHCS Commercial |
$3,321.01
|
| Rate for Payer: United Healthcare All Payer |
$3,044.26
|
|
|
BENLYSTA 10 MG [400MG VIAL]
|
Facility
|
IP
|
$11,530.57
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,459.17 |
| Max. Negotiated Rate |
$11,069.35 |
| Rate for Payer: Aetna Commercial |
$8,878.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,993.84
|
| Rate for Payer: Cash Price |
$5,765.28
|
| Rate for Payer: Cigna Commercial |
$9,570.37
|
| Rate for Payer: First Health Commercial |
$10,954.04
|
| Rate for Payer: Humana Commercial |
$9,800.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,455.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,509.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,459.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,146.90
|
| Rate for Payer: Ohio Health Group HMO |
$8,647.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,224.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,031.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,956.09
|
| Rate for Payer: PHCS Commercial |
$11,069.35
|
| Rate for Payer: United Healthcare All Payer |
$10,146.90
|
|
|
BENLYSTA 10 MG [400MG VIAL]
|
Facility
|
OP
|
$11,530.57
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
25001885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.01 |
| Max. Negotiated Rate |
$11,069.35 |
| Rate for Payer: Aetna Commercial |
$8,878.54
|
| Rate for Payer: Anthem Medicaid |
$3,965.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$56.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,993.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.61
|
| Rate for Payer: Cash Price |
$5,765.28
|
| Rate for Payer: Cash Price |
$5,765.28
|
| Rate for Payer: Cigna Commercial |
$9,570.37
|
| Rate for Payer: First Health Commercial |
$10,954.04
|
| Rate for Payer: Humana Commercial |
$9,800.98
|
| Rate for Payer: Humana KY Medicaid |
$3,965.36
|
| Rate for Payer: Humana Medicare Advantage |
$56.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,005.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,455.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,509.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,044.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,146.90
|
| Rate for Payer: Ohio Health Group HMO |
$8,647.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,224.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,031.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,956.09
|
| Rate for Payer: PHCS Commercial |
$11,069.35
|
| Rate for Payer: United Healthcare All Payer |
$10,146.90
|
|
|
BENTSON ST. WIRE 145CM
|
Facility
|
IP
|
$499.93
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.98 |
| Max. Negotiated Rate |
$479.93 |
| Rate for Payer: Aetna Commercial |
$384.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.95
|
| Rate for Payer: Cash Price |
$249.97
|
| Rate for Payer: Cigna Commercial |
$414.94
|
| Rate for Payer: First Health Commercial |
$474.93
|
| Rate for Payer: Humana Commercial |
$424.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.94
|
| Rate for Payer: Ohio Health Group HMO |
$374.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$434.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$344.95
|
| Rate for Payer: PHCS Commercial |
$479.93
|
| Rate for Payer: United Healthcare All Payer |
$439.94
|
|
|
BENTSON ST. WIRE 145CM
|
Facility
|
OP
|
$499.93
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.98 |
| Max. Negotiated Rate |
$479.93 |
| Rate for Payer: Aetna Commercial |
$384.95
|
| Rate for Payer: Anthem Medicaid |
$171.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.95
|
| Rate for Payer: Cash Price |
$249.97
|
| Rate for Payer: Cigna Commercial |
$414.94
|
| Rate for Payer: First Health Commercial |
$474.93
|
| Rate for Payer: Humana Commercial |
$424.94
|
| Rate for Payer: Humana KY Medicaid |
$171.93
|
| Rate for Payer: Kentucky WC Medicaid |
$173.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.94
|
| Rate for Payer: Ohio Health Group HMO |
$374.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$434.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$344.95
|
| Rate for Payer: PHCS Commercial |
$479.93
|
| Rate for Payer: United Healthcare All Payer |
$439.94
|
|
|
BENTYL (DICYCLOMINE) 10MG/1CAP
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
25000323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
BENTYL (DICYCLOMINE) 10MG/1CAP
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
25000323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
BENTYL(DICYCLOMINE) 1 10MG/5ML
|
Facility
|
IP
|
$9.20
|
|
|
Service Code
|
NDC 603116158
|
| Hospital Charge Code |
25000325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Aetna Commercial |
$7.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.18
|
| Rate for Payer: Cash Price |
$4.60
|
| Rate for Payer: Cigna Commercial |
$7.64
|
| Rate for Payer: First Health Commercial |
$8.74
|
| Rate for Payer: Humana Commercial |
$7.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.10
|
| Rate for Payer: Ohio Health Group HMO |
$6.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.35
|
| Rate for Payer: PHCS Commercial |
$8.83
|
| Rate for Payer: United Healthcare All Payer |
$8.10
|
|
