|
BENTYL(DICYCLOMINE) 1 10MG/5ML
|
Facility
|
OP
|
$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 Medicaid |
$3.16
|
| 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: Humana KY Medicaid |
$3.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3.20
|
| 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: Molina Healthcare Medicaid |
$3.23
|
| 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
|
|
|
BENTYL (DICYCLOMINE) 20MG/1TAB
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 60687038001
|
| Hospital Charge Code |
25000324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.21
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
BENTYL (DICYCLOMINE) 20MG/1TAB
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 60687038001
|
| Hospital Charge Code |
25000324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.21
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
BENTYL (DICYCLOMINE) 20MG/2ML
|
Facility
|
IP
|
$353.06
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
25001887
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.92 |
| Max. Negotiated Rate |
$338.94 |
| Rate for Payer: Aetna Commercial |
$271.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$275.39
|
| Rate for Payer: Cash Price |
$176.53
|
| Rate for Payer: Cigna Commercial |
$293.04
|
| Rate for Payer: First Health Commercial |
$335.41
|
| Rate for Payer: Humana Commercial |
$300.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$289.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$260.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$310.69
|
| Rate for Payer: Ohio Health Group HMO |
$264.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.61
|
| Rate for Payer: PHCS Commercial |
$338.94
|
| Rate for Payer: United Healthcare All Payer |
$310.69
|
|
|
BENTYL (DICYCLOMINE) 20MG/2ML
|
Facility
|
OP
|
$353.06
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
25001887
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.92 |
| Max. Negotiated Rate |
$338.94 |
| Rate for Payer: Aetna Commercial |
$271.86
|
| Rate for Payer: Anthem Medicaid |
$121.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$275.39
|
| Rate for Payer: Cash Price |
$176.53
|
| Rate for Payer: Cigna Commercial |
$293.04
|
| Rate for Payer: First Health Commercial |
$335.41
|
| Rate for Payer: Humana Commercial |
$300.10
|
| Rate for Payer: Humana KY Medicaid |
$121.42
|
| Rate for Payer: Kentucky WC Medicaid |
$122.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$289.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$260.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$310.69
|
| Rate for Payer: Ohio Health Group HMO |
$264.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.61
|
| Rate for Payer: PHCS Commercial |
$338.94
|
| Rate for Payer: United Healthcare All Payer |
$310.69
|
|
|
BERMUDA GRASS IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000816
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
BERMUDA GRASS IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000816
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
BESIVANCE 0.6% 5ML PER BOTTLE
|
Facility
|
OP
|
$648.04
|
|
|
Service Code
|
NDC 24208044605
|
| Hospital Charge Code |
25000327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.41 |
| Max. Negotiated Rate |
$622.12 |
| Rate for Payer: Aetna Commercial |
$498.99
|
| Rate for Payer: Anthem Medicaid |
$222.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$505.47
|
| Rate for Payer: Cash Price |
$324.02
|
| Rate for Payer: Cigna Commercial |
$537.87
|
| Rate for Payer: First Health Commercial |
$615.64
|
| Rate for Payer: Humana Commercial |
$550.83
|
| Rate for Payer: Humana KY Medicaid |
$222.86
|
| Rate for Payer: Kentucky WC Medicaid |
$225.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$531.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$478.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$227.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$570.28
|
| Rate for Payer: Ohio Health Group HMO |
$486.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$518.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$563.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.15
|
| Rate for Payer: PHCS Commercial |
$622.12
|
| Rate for Payer: United Healthcare All Payer |
$570.28
|
|
|
BESIVANCE 0.6% 5ML PER BOTTLE
|
Facility
|
IP
|
$648.04
|
|
|
Service Code
|
NDC 24208044605
|
| Hospital Charge Code |
25000327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.41 |
| Max. Negotiated Rate |
$622.12 |
| Rate for Payer: Aetna Commercial |
$498.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$505.47
|
| Rate for Payer: Cash Price |
$324.02
|
| Rate for Payer: Cigna Commercial |
$537.87
|
| Rate for Payer: First Health Commercial |
$615.64
|
| Rate for Payer: Humana Commercial |
$550.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$531.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$478.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$570.28
|
| Rate for Payer: Ohio Health Group HMO |
$486.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$518.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$563.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.15
|
| Rate for Payer: PHCS Commercial |
$622.12
|
| Rate for Payer: United Healthcare All Payer |
$570.28
|
|
|
BETADINE 0.35% 1,000ML LAVAGE
|
Facility
|
OP
|
$327.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003740
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$314.43 |
| Rate for Payer: Aetna Commercial |
$252.20
|
| Rate for Payer: Anthem Medicaid |
$112.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.47
|
| Rate for Payer: Cash Price |
$163.76
|
| Rate for Payer: Cigna Commercial |
$271.85
|
| Rate for Payer: First Health Commercial |
$311.15
|
| Rate for Payer: Humana Commercial |
$278.40
|
| Rate for Payer: Humana KY Medicaid |
$112.64
|
| Rate for Payer: Kentucky WC Medicaid |
$113.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$288.23
|
| Rate for Payer: Ohio Health Group HMO |
$245.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$226.00
|
| Rate for Payer: PHCS Commercial |
$314.43
|
| Rate for Payer: United Healthcare All Payer |
$288.23
|
|
|
BETADINE 0.35% 1,000ML LAVAGE
|
Facility
|
IP
|
$327.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003740
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$314.43 |
| Rate for Payer: Aetna Commercial |
$252.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.47
|
| Rate for Payer: Cash Price |
$163.76
|
| Rate for Payer: Cigna Commercial |
$271.85
|
| Rate for Payer: First Health Commercial |
$311.15
|
| Rate for Payer: Humana Commercial |
$278.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$288.23
|
| Rate for Payer: Ohio Health Group HMO |
$245.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$226.00
|
| Rate for Payer: PHCS Commercial |
$314.43
|
| Rate for Payer: United Healthcare All Payer |
$288.23
|
|
|
BETADINE 0.35% 500ML LAVAGE
|
Facility
|
IP
|
$327.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004574
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$314.43 |
| Rate for Payer: Aetna Commercial |
$252.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.47
|
| Rate for Payer: Cash Price |
$163.76
|
| Rate for Payer: Cigna Commercial |
$271.85
|
| Rate for Payer: First Health Commercial |
$311.15
|
| Rate for Payer: Humana Commercial |
$278.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$288.23
|
| Rate for Payer: Ohio Health Group HMO |
$245.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$226.00
|
| Rate for Payer: PHCS Commercial |
$314.43
|
| Rate for Payer: United Healthcare All Payer |
$288.23
|
|
|
BETADINE 0.35% 500ML LAVAGE
|
Facility
|
OP
|
$327.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004574
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$314.43 |
| Rate for Payer: Aetna Commercial |
$252.20
|
| Rate for Payer: Anthem Medicaid |
$112.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.47
|
| Rate for Payer: Cash Price |
$163.76
|
| Rate for Payer: Cigna Commercial |
$271.85
|
| Rate for Payer: First Health Commercial |
$311.15
|
| Rate for Payer: Humana Commercial |
$278.40
|
| Rate for Payer: Humana KY Medicaid |
$112.64
|
| Rate for Payer: Kentucky WC Medicaid |
$113.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$288.23
|
| Rate for Payer: Ohio Health Group HMO |
$245.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$226.00
|
| Rate for Payer: PHCS Commercial |
$314.43
|
| Rate for Payer: United Healthcare All Payer |
$288.23
|
|
|
BETADINE 5% OPTH 30 ML
|
Facility
|
OP
|
$92.76
|
|
|
Service Code
|
NDC 65041130
|
| Hospital Charge Code |
25002887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.83 |
| Max. Negotiated Rate |
$89.05 |
| Rate for Payer: Aetna Commercial |
$71.43
|
| Rate for Payer: Anthem Medicaid |
$31.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.35
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Cigna Commercial |
$76.99
|
| Rate for Payer: First Health Commercial |
$88.12
|
| Rate for Payer: Humana Commercial |
$78.85
|
| Rate for Payer: Humana KY Medicaid |
$31.90
|
| Rate for Payer: Kentucky WC Medicaid |
$32.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.63
|
| Rate for Payer: Ohio Health Group HMO |
$69.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.00
|
| Rate for Payer: PHCS Commercial |
$89.05
|
| Rate for Payer: United Healthcare All Payer |
$81.63
|
|
|
BETADINE 5% OPTH 30 ML
|
Facility
|
IP
|
$92.76
|
|
|
Service Code
|
NDC 65041130
|
| Hospital Charge Code |
25002887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.83 |
| Max. Negotiated Rate |
$89.05 |
| Rate for Payer: Aetna Commercial |
$71.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.35
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Cigna Commercial |
$76.99
|
| Rate for Payer: First Health Commercial |
$88.12
|
| Rate for Payer: Humana Commercial |
$78.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.63
|
| Rate for Payer: Ohio Health Group HMO |
$69.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.00
|
| Rate for Payer: PHCS Commercial |
$89.05
|
| Rate for Payer: United Healthcare All Payer |
$81.63
|
|
|
BETADINE 5% OPTHAL 30ML
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
25002887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BETADINE 5% OPTHAL 30ML
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
25002887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BETADINE (POVID IOD) SOLN .5OZ
|
Facility
|
OP
|
$9.44
|
|
|
Service Code
|
NDC 67618015005
|
| Hospital Charge Code |
25002885
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.06 |
| Rate for Payer: Aetna Commercial |
$7.27
|
| Rate for Payer: Anthem Medicaid |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.97
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Humana KY Medicaid |
$3.25
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.31
|
| Rate for Payer: Ohio Health Group HMO |
$7.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.51
|
| Rate for Payer: PHCS Commercial |
$9.06
|
| Rate for Payer: United Healthcare All Payer |
$8.31
|
|
|
BETADINE (POVID IOD) SOLN .5OZ
|
Facility
|
IP
|
$9.44
|
|
|
Service Code
|
NDC 67618015005
|
| Hospital Charge Code |
25002885
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.06 |
| Rate for Payer: Aetna Commercial |
$7.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.97
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.31
|
| Rate for Payer: Ohio Health Group HMO |
$7.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.51
|
| Rate for Payer: PHCS Commercial |
$9.06
|
| Rate for Payer: United Healthcare All Payer |
$8.31
|
|
|
BETADINE (POVIDONE IOD) OI 1OZ
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 536127180
|
| Hospital Charge Code |
25000328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
BETADINE (POVIDONE IOD) OI 1OZ
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 536127180
|
| Hospital Charge Code |
25000328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
BETADINE SWAB 1 EACH
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 67618015301
|
| Hospital Charge Code |
25003859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
BETADINE SWAB 1 EACH
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 67618015301
|
| Hospital Charge Code |
25003859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
BETAGAN (LEVOBUNOLOL)0.5% 5ML
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 24208050505
|
| Hospital Charge Code |
25000329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna Commercial |
$0.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.73
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna Commercial |
$0.77
|
| Rate for Payer: First Health Commercial |
$0.88
|
| Rate for Payer: Humana Commercial |
$0.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.82
|
| Rate for Payer: Ohio Health Group HMO |
$0.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.64
|
| Rate for Payer: PHCS Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Payer |
$0.82
|
|
|
BETAGAN (LEVOBUNOLOL)0.5% 5ML
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 24208050505
|
| Hospital Charge Code |
25000329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna Commercial |
$0.72
|
| Rate for Payer: Anthem Medicaid |
$0.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.73
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna Commercial |
$0.77
|
| Rate for Payer: First Health Commercial |
$0.88
|
| Rate for Payer: Humana Commercial |
$0.79
|
| Rate for Payer: Humana KY Medicaid |
$0.32
|
| Rate for Payer: Kentucky WC Medicaid |
$0.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.82
|
| Rate for Payer: Ohio Health Group HMO |
$0.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.64
|
| Rate for Payer: PHCS Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Payer |
$0.82
|
|
