|
CHLORASEPTIC (PHENOL) SPRA 6OZ
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 78112001104
|
| Hospital Charge Code |
25000415
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
|
CHLORIDE - BLOOD
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS 82435
|
| Hospital Charge Code |
30000277
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.77
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.67
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
CHLORIDE - BLOOD
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS 82435
|
| Hospital Charge Code |
30000277
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem Medicaid |
$4.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.60
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Humana KY Medicaid |
$4.60
|
| Rate for Payer: Humana Medicare Advantage |
$4.60
|
| Rate for Payer: Kentucky WC Medicaid |
$4.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.67
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
CHLOROPROC1%+EPI1:200K 30mLMDV
|
Facility
|
OP
|
$125.04
|
|
|
Service Code
|
NDC 63323047537
|
| Hospital Charge Code |
25004308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$120.04 |
| Rate for Payer: Aetna Commercial |
$96.28
|
| Rate for Payer: Anthem Medicaid |
$43.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.53
|
| Rate for Payer: Cash Price |
$62.52
|
| Rate for Payer: Cigna Commercial |
$103.78
|
| Rate for Payer: First Health Commercial |
$118.79
|
| Rate for Payer: Humana Commercial |
$106.28
|
| Rate for Payer: Humana KY Medicaid |
$43.00
|
| Rate for Payer: Kentucky WC Medicaid |
$43.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.04
|
| Rate for Payer: Ohio Health Group HMO |
$93.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.76
|
| Rate for Payer: PHCS Commercial |
$120.04
|
| Rate for Payer: United Healthcare All Payer |
$110.04
|
|
|
CHLOROPROC1%+EPI1:200K 30mLMDV
|
Facility
|
IP
|
$125.04
|
|
|
Service Code
|
NDC 63323047537
|
| Hospital Charge Code |
25004308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$120.04 |
| Rate for Payer: Aetna Commercial |
$96.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.53
|
| Rate for Payer: Cash Price |
$62.52
|
| Rate for Payer: Cigna Commercial |
$103.78
|
| Rate for Payer: First Health Commercial |
$118.79
|
| Rate for Payer: Humana Commercial |
$106.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.04
|
| Rate for Payer: Ohio Health Group HMO |
$93.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.76
|
| Rate for Payer: PHCS Commercial |
$120.04
|
| Rate for Payer: United Healthcare All Payer |
$110.04
|
|
|
CHLOROPROCAINE 1% 1mg(30mLMD
|
Facility
|
IP
|
$98.32
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
25004299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.78 |
| Max. Negotiated Rate |
$94.39 |
| Rate for Payer: Aetna Commercial |
$75.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.69
|
| Rate for Payer: Cash Price |
$49.16
|
| Rate for Payer: Cigna Commercial |
$81.61
|
| Rate for Payer: First Health Commercial |
$93.40
|
| Rate for Payer: Humana Commercial |
$83.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.52
|
| Rate for Payer: Ohio Health Group HMO |
$73.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.48
|
| Rate for Payer: PHCS Commercial |
$94.39
|
| Rate for Payer: United Healthcare All Payer |
$86.52
|
|
|
CHLOROPROCAINE 1% 1mg(30mLMD
|
Facility
|
OP
|
$98.32
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
25004299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$94.39 |
| Rate for Payer: Aetna Commercial |
$75.71
|
| Rate for Payer: Anthem Medicaid |
$33.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$49.16
|
| Rate for Payer: Cash Price |
$49.16
|
| Rate for Payer: Cigna Commercial |
$81.61
|
| Rate for Payer: First Health Commercial |
$93.40
|
| Rate for Payer: Humana Commercial |
$83.57
|
| Rate for Payer: Humana KY Medicaid |
$33.81
|
| Rate for Payer: Humana Medicare Advantage |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$34.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.52
|
| Rate for Payer: Ohio Health Group HMO |
$73.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.48
|
| Rate for Payer: PHCS Commercial |
$94.39
|
| Rate for Payer: United Healthcare All Payer |
$86.52
|
|
|
CHLOROPROCAINE 2% 1mg(20mLSD
|
Facility
|
IP
|
$128.31
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
25002283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.68 |
| Max. Negotiated Rate |
$123.18 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.08
|
| Rate for Payer: Cash Price |
$64.16
|
| Rate for Payer: Cigna Commercial |
$106.50
|
| Rate for Payer: First Health Commercial |
$121.89
|
| Rate for Payer: Humana Commercial |
$109.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.91
|
| Rate for Payer: Ohio Health Group HMO |
$96.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.78
|
| Rate for Payer: PHCS Commercial |
$123.18
|
| Rate for Payer: United Healthcare All Payer |
$112.91
|
|
|
CHLOROPROCAINE 2% 1mg(20mLSD
|
Facility
|
OP
|
$128.31
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
25002283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$123.18 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Anthem Medicaid |
$44.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$64.16
|
| Rate for Payer: Cash Price |
$64.16
|
| Rate for Payer: Cigna Commercial |
$106.50
|
| Rate for Payer: First Health Commercial |
$121.89
|
| Rate for Payer: Humana Commercial |
$109.06
|
| Rate for Payer: Humana KY Medicaid |
$44.13
|
| Rate for Payer: Humana Medicare Advantage |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$44.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.91
|
| Rate for Payer: Ohio Health Group HMO |
$96.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.78
|
| Rate for Payer: PHCS Commercial |
$123.18
|
| Rate for Payer: United Healthcare All Payer |
$112.91
|
|
|
CHLOROPROCAINE 3% 1mg(20mLSD
|
Facility
|
OP
|
$189.57
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
25002284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$181.99 |
| Rate for Payer: Aetna Commercial |
$145.97
|
| Rate for Payer: Anthem Medicaid |
$65.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$94.78
|
| Rate for Payer: Cash Price |
$94.78
|
| Rate for Payer: Cigna Commercial |
$157.34
|
| Rate for Payer: First Health Commercial |
$180.09
|
| Rate for Payer: Humana Commercial |
$161.13
|
| Rate for Payer: Humana KY Medicaid |
$65.19
|
| Rate for Payer: Humana Medicare Advantage |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$65.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.82
|
| Rate for Payer: Ohio Health Group HMO |
$142.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.77
|
| Rate for Payer: PHCS Commercial |
$181.99
|
| Rate for Payer: United Healthcare All Payer |
$166.82
|
|
|
CHLOROPROCAINE 3% 1mg(20mLSD
|
Facility
|
IP
|
$189.57
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
25002284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$181.99 |
| Rate for Payer: Aetna Commercial |
$145.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.86
|
| Rate for Payer: Cash Price |
$94.78
|
| Rate for Payer: Cigna Commercial |
$157.34
|
| Rate for Payer: First Health Commercial |
$180.09
|
| Rate for Payer: Humana Commercial |
$161.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.82
|
| Rate for Payer: Ohio Health Group HMO |
$142.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.77
|
| Rate for Payer: PHCS Commercial |
$181.99
|
| Rate for Payer: United Healthcare All Payer |
$166.82
|
|
|
CHLORPROMAZINE 10MG TABLET
|
Facility
|
OP
|
$4.90
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
25002701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cigna Commercial |
$4.07
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.31
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Payer |
$4.31
|
|
|
CHLORPROMAZINE 10MG TABLET
|
Facility
|
IP
|
$4.90
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
25002701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cigna Commercial |
$4.07
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.31
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Payer |
$4.31
|
|
|
CHLORPROMAZINE 25MG/1ML AMP
|
Facility
|
IP
|
$184.89
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
25004278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.04 |
| Max. Negotiated Rate |
$177.49 |
| Rate for Payer: Aetna Commercial |
$142.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.21
|
| Rate for Payer: Cash Price |
$92.44
|
| Rate for Payer: Cigna Commercial |
$153.46
|
| Rate for Payer: First Health Commercial |
$175.65
|
| Rate for Payer: Humana Commercial |
$157.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.70
|
| Rate for Payer: Ohio Health Group HMO |
$138.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.32
|
| Rate for Payer: PHCS Commercial |
$177.49
|
| Rate for Payer: United Healthcare All Payer |
$162.70
|
|
|
CHLORPROMAZINE 25MG/1ML AMP
|
Facility
|
OP
|
$184.89
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
25004278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.04 |
| Max. Negotiated Rate |
$177.49 |
| Rate for Payer: Aetna Commercial |
$142.37
|
| Rate for Payer: Anthem Medicaid |
$63.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.21
|
| Rate for Payer: Cash Price |
$92.44
|
| Rate for Payer: Cigna Commercial |
$153.46
|
| Rate for Payer: First Health Commercial |
$175.65
|
| Rate for Payer: Humana Commercial |
$157.16
|
| Rate for Payer: Humana KY Medicaid |
$63.58
|
| Rate for Payer: Kentucky WC Medicaid |
$64.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.70
|
| Rate for Payer: Ohio Health Group HMO |
$138.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.32
|
| Rate for Payer: PHCS Commercial |
$177.49
|
| Rate for Payer: United Healthcare All Payer |
$162.70
|
|
|
CHLORZOXAZONE 500 M 500MG/1TAB
|
Facility
|
IP
|
$4.48
|
|
|
Service Code
|
NDC 591252001
|
| Hospital Charge Code |
25000416
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.30 |
| Rate for Payer: Aetna Commercial |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.72
|
| Rate for Payer: First Health Commercial |
$4.26
|
| Rate for Payer: Humana Commercial |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.30
|
| Rate for Payer: United Healthcare All Payer |
$3.94
|
|
|
CHLORZOXAZONE 500 M 500MG/1TAB
|
Facility
|
OP
|
$4.48
|
|
|
Service Code
|
NDC 591252001
|
| Hospital Charge Code |
25000416
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.30 |
| Rate for Payer: Aetna Commercial |
$3.45
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.72
|
| Rate for Payer: First Health Commercial |
$4.26
|
| Rate for Payer: Humana Commercial |
$3.81
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.30
|
| Rate for Payer: United Healthcare All Payer |
$3.94
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Facility
|
OP
|
$2,451.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
76102008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$318.63 |
| Max. Negotiated Rate |
$2,352.96 |
| Rate for Payer: Aetna Commercial |
$1,887.27
|
| Rate for Payer: Anthem Medicaid |
$842.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,911.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$1,225.50
|
| Rate for Payer: Cash Price |
$1,225.50
|
| Rate for Payer: Cigna Commercial |
$2,034.33
|
| Rate for Payer: First Health Commercial |
$2,328.45
|
| Rate for Payer: Humana Commercial |
$2,083.35
|
| Rate for Payer: Humana KY Medicaid |
$842.90
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$851.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,009.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,808.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$859.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,156.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,838.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$490.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$318.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.81
|
| Rate for Payer: PHCS Commercial |
$2,352.96
|
| Rate for Payer: United Healthcare All Payer |
$2,156.88
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Facility
|
IP
|
$1,551.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
761T2008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.63 |
| Max. Negotiated Rate |
$1,488.96 |
| Rate for Payer: Aetna Commercial |
$1,194.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,209.78
|
| Rate for Payer: Cash Price |
$775.50
|
| Rate for Payer: Cigna Commercial |
$1,287.33
|
| Rate for Payer: First Health Commercial |
$1,473.45
|
| Rate for Payer: Humana Commercial |
$1,318.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,271.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,144.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$465.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,364.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,163.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$310.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$480.81
|
| Rate for Payer: PHCS Commercial |
$1,488.96
|
| Rate for Payer: United Healthcare All Payer |
$1,364.88
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Facility
|
IP
|
$1,174.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
45000276
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.62 |
| Max. Negotiated Rate |
$1,127.04 |
| Rate for Payer: Aetna Commercial |
$903.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$915.72
|
| Rate for Payer: Cash Price |
$587.00
|
| Rate for Payer: Cigna Commercial |
$974.42
|
| Rate for Payer: First Health Commercial |
$1,115.30
|
| Rate for Payer: Humana Commercial |
$997.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$962.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$866.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,033.12
|
| Rate for Payer: Ohio Health Group HMO |
$880.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.94
|
| Rate for Payer: PHCS Commercial |
$1,127.04
|
| Rate for Payer: United Healthcare All Payer |
$1,033.12
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Facility
|
OP
|
$1,551.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
761T2008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.63 |
| Max. Negotiated Rate |
$1,488.96 |
| Rate for Payer: Aetna Commercial |
$1,194.27
|
| Rate for Payer: Anthem Medicaid |
$533.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,209.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$775.50
|
| Rate for Payer: Cash Price |
$775.50
|
| Rate for Payer: Cigna Commercial |
$1,287.33
|
| Rate for Payer: First Health Commercial |
$1,473.45
|
| Rate for Payer: Humana Commercial |
$1,318.35
|
| Rate for Payer: Humana KY Medicaid |
$533.39
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$538.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,271.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,144.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$544.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,364.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,163.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$310.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$480.81
|
| Rate for Payer: PHCS Commercial |
$1,488.96
|
| Rate for Payer: United Healthcare All Payer |
$1,364.88
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Professional
|
Both
|
$2,451.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
76102008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.85 |
| Max. Negotiated Rate |
$2,451.00 |
| Rate for Payer: Aetna Commercial |
$152.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$85.49
|
| Rate for Payer: Anthem Medicaid |
$76.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,451.00
|
| Rate for Payer: Cash Price |
$1,225.50
|
| Rate for Payer: Cash Price |
$1,225.50
|
| Rate for Payer: Cigna Commercial |
$137.18
|
| Rate for Payer: Healthspan PPO |
$855.37
|
| Rate for Payer: Humana Medicaid |
$76.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.39
|
| Rate for Payer: Molina Healthcare Passport |
$76.85
|
| Rate for Payer: Multiplan PHCS |
$1,470.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,715.70
|
| Rate for Payer: UHCCP Medicaid |
$89.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$77.62
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
761P2008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.85 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$152.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$85.49
|
| Rate for Payer: Anthem Medicaid |
$76.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$137.18
|
| Rate for Payer: Healthspan PPO |
$855.37
|
| Rate for Payer: Humana Medicaid |
$76.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.39
|
| Rate for Payer: Molina Healthcare Passport |
$76.85
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$89.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$77.62
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Facility
|
IP
|
$2,451.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
76102008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$318.63 |
| Max. Negotiated Rate |
$2,352.96 |
| Rate for Payer: Aetna Commercial |
$1,887.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,911.78
|
| Rate for Payer: Cash Price |
$1,225.50
|
| Rate for Payer: Cigna Commercial |
$2,034.33
|
| Rate for Payer: First Health Commercial |
$2,328.45
|
| Rate for Payer: Humana Commercial |
$2,083.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,009.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,808.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$735.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,156.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,838.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$490.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$318.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.81
|
| Rate for Payer: PHCS Commercial |
$2,352.96
|
| Rate for Payer: United Healthcare All Payer |
$2,156.88
|
|
|
CHNG DUOD JEJUN TUBEPERC WFLUO
|
Facility
|
OP
|
$1,174.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
45000276
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.62 |
| Max. Negotiated Rate |
$1,127.04 |
| Rate for Payer: Aetna Commercial |
$903.98
|
| Rate for Payer: Anthem Medicaid |
$403.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$915.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$587.00
|
| Rate for Payer: Cash Price |
$587.00
|
| Rate for Payer: Cigna Commercial |
$974.42
|
| Rate for Payer: First Health Commercial |
$1,115.30
|
| Rate for Payer: Humana Commercial |
$997.90
|
| Rate for Payer: Humana KY Medicaid |
$403.74
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$407.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$962.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$866.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$411.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,033.12
|
| Rate for Payer: Ohio Health Group HMO |
$880.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.94
|
| Rate for Payer: PHCS Commercial |
$1,127.04
|
| Rate for Payer: United Healthcare All Payer |
$1,033.12
|
|
