|
CLINIMIX E 4.25% 10% (1000ML)
|
Facility
|
IP
|
$111.55
|
|
|
Service Code
|
NDC 338114503
|
| Hospital Charge Code |
25002951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.50 |
| Max. Negotiated Rate |
$107.09 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.01
|
| Rate for Payer: Cash Price |
$55.77
|
| Rate for Payer: Cigna Commercial |
$92.59
|
| Rate for Payer: First Health Commercial |
$105.97
|
| Rate for Payer: Humana Commercial |
$94.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.16
|
| Rate for Payer: Ohio Health Group HMO |
$83.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.58
|
| Rate for Payer: PHCS Commercial |
$107.09
|
| Rate for Payer: United Healthcare All Payer |
$98.16
|
|
|
CLINIMIX E 4.25% 10% (2000ML)
|
Facility
|
IP
|
$219.18
|
|
|
Service Code
|
NDC 338111504
|
| Hospital Charge Code |
25002952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$210.41 |
| Rate for Payer: Aetna Commercial |
$168.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.96
|
| Rate for Payer: Cash Price |
$109.59
|
| Rate for Payer: Cigna Commercial |
$181.92
|
| Rate for Payer: First Health Commercial |
$208.22
|
| Rate for Payer: Humana Commercial |
$186.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.88
|
| Rate for Payer: Ohio Health Group HMO |
$164.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.95
|
| Rate for Payer: PHCS Commercial |
$210.41
|
| Rate for Payer: United Healthcare All Payer |
$192.88
|
|
|
CLINIMIX E 4.25% 10% (2000ML)
|
Facility
|
OP
|
$219.18
|
|
|
Service Code
|
NDC 338111504
|
| Hospital Charge Code |
25002952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$210.41 |
| Rate for Payer: Aetna Commercial |
$168.77
|
| Rate for Payer: Anthem Medicaid |
$75.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.96
|
| Rate for Payer: Cash Price |
$109.59
|
| Rate for Payer: Cigna Commercial |
$181.92
|
| Rate for Payer: First Health Commercial |
$208.22
|
| Rate for Payer: Humana Commercial |
$186.30
|
| Rate for Payer: Humana KY Medicaid |
$75.38
|
| Rate for Payer: Kentucky WC Medicaid |
$76.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.88
|
| Rate for Payer: Ohio Health Group HMO |
$164.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.95
|
| Rate for Payer: PHCS Commercial |
$210.41
|
| Rate for Payer: United Healthcare All Payer |
$192.88
|
|
|
CLINIMIX E 5%/15% (1000 ML)
|
Facility
|
IP
|
$108.91
|
|
|
Service Code
|
NDC 338114703
|
| Hospital Charge Code |
25002954
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$83.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna Commercial |
$90.40
|
| Rate for Payer: First Health Commercial |
$103.46
|
| Rate for Payer: Humana Commercial |
$92.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.84
|
| Rate for Payer: Ohio Health Group HMO |
$81.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.76
|
| Rate for Payer: PHCS Commercial |
$104.55
|
| Rate for Payer: United Healthcare All Payer |
$95.84
|
|
|
CLINIMIX E 5%/15% (1000 ML)
|
Facility
|
OP
|
$108.91
|
|
|
Service Code
|
NDC 338114703
|
| Hospital Charge Code |
25002954
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$83.86
|
| Rate for Payer: Anthem Medicaid |
$37.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna Commercial |
$90.40
|
| Rate for Payer: First Health Commercial |
$103.46
|
| Rate for Payer: Humana Commercial |
$92.57
|
| Rate for Payer: Humana KY Medicaid |
$37.45
|
| Rate for Payer: Kentucky WC Medicaid |
$37.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.84
|
| Rate for Payer: Ohio Health Group HMO |
$81.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.76
|
| Rate for Payer: PHCS Commercial |
$104.55
|
| Rate for Payer: United Healthcare All Payer |
$95.84
|
|
|
CLINIMIX E 5% 15% (2000ML)
|
Facility
|
IP
|
$223.66
|
|
|
Service Code
|
NDC 338112304
|
| Hospital Charge Code |
25002953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.08 |
| Max. Negotiated Rate |
$214.71 |
| Rate for Payer: Aetna Commercial |
$172.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$174.45
|
| Rate for Payer: Cash Price |
$111.83
|
| Rate for Payer: Cigna Commercial |
$185.64
|
| Rate for Payer: First Health Commercial |
$212.48
|
| Rate for Payer: Humana Commercial |
$190.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$183.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$165.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$196.82
|
| Rate for Payer: Ohio Health Group HMO |
$167.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.33
|
| Rate for Payer: PHCS Commercial |
$214.71
|
| Rate for Payer: United Healthcare All Payer |
$196.82
|
|
|
CLINIMIX E 5% 15% (2000ML)
|
Facility
|
OP
|
$223.66
|
|
|
Service Code
|
NDC 338112304
|
| Hospital Charge Code |
25002953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.08 |
| Max. Negotiated Rate |
$214.71 |
| Rate for Payer: Aetna Commercial |
$172.22
|
| Rate for Payer: Anthem Medicaid |
$76.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$174.45
|
| Rate for Payer: Cash Price |
$111.83
|
| Rate for Payer: Cigna Commercial |
$185.64
|
| Rate for Payer: First Health Commercial |
$212.48
|
| Rate for Payer: Humana Commercial |
$190.11
|
| Rate for Payer: Humana KY Medicaid |
$76.92
|
| Rate for Payer: Kentucky WC Medicaid |
$77.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$183.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$165.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$78.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$196.82
|
| Rate for Payer: Ohio Health Group HMO |
$167.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.33
|
| Rate for Payer: PHCS Commercial |
$214.71
|
| Rate for Payer: United Healthcare All Payer |
$196.82
|
|
|
CLIPS LIGATING TI 20 SILVER ME
|
Facility
|
OP
|
$749.93
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$97.49 |
| Max. Negotiated Rate |
$719.93 |
| Rate for Payer: Aetna Commercial |
$577.45
|
| Rate for Payer: Anthem Medicaid |
$257.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$584.95
|
| Rate for Payer: Cash Price |
$374.97
|
| Rate for Payer: Cigna Commercial |
$622.44
|
| Rate for Payer: First Health Commercial |
$712.43
|
| Rate for Payer: Humana Commercial |
$637.44
|
| Rate for Payer: Humana KY Medicaid |
$257.90
|
| Rate for Payer: Kentucky WC Medicaid |
$260.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$614.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$224.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$659.94
|
| Rate for Payer: Ohio Health Group HMO |
$562.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.48
|
| Rate for Payer: PHCS Commercial |
$719.93
|
| Rate for Payer: United Healthcare All Payer |
$659.94
|
|
|
CLIPS LIGATING TI 20 SILVER ME
|
Facility
|
IP
|
$749.93
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$97.49 |
| Max. Negotiated Rate |
$719.93 |
| Rate for Payer: Aetna Commercial |
$577.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$584.95
|
| Rate for Payer: Cash Price |
$374.97
|
| Rate for Payer: Cigna Commercial |
$622.44
|
| Rate for Payer: First Health Commercial |
$712.43
|
| Rate for Payer: Humana Commercial |
$637.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$614.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$224.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$659.94
|
| Rate for Payer: Ohio Health Group HMO |
$562.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.48
|
| Rate for Payer: PHCS Commercial |
$719.93
|
| Rate for Payer: United Healthcare All Payer |
$659.94
|
|
|
CLOBAZAM 10mg TABLET
|
Facility
|
IP
|
$61.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna Commercial |
$47.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.93
|
| Rate for Payer: Cash Price |
$30.73
|
| Rate for Payer: Cigna Commercial |
$51.00
|
| Rate for Payer: First Health Commercial |
$58.38
|
| Rate for Payer: Humana Commercial |
$52.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.08
|
| Rate for Payer: Ohio Health Group HMO |
$46.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.05
|
| Rate for Payer: PHCS Commercial |
$58.99
|
| Rate for Payer: United Healthcare All Payer |
$54.08
|
|
|
CLOBAZAM 10mg TABLET
|
Facility
|
OP
|
$61.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna Commercial |
$47.32
|
| Rate for Payer: Anthem Medicaid |
$21.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.93
|
| Rate for Payer: Cash Price |
$30.73
|
| Rate for Payer: Cigna Commercial |
$51.00
|
| Rate for Payer: First Health Commercial |
$58.38
|
| Rate for Payer: Humana Commercial |
$52.23
|
| Rate for Payer: Humana KY Medicaid |
$21.13
|
| Rate for Payer: Kentucky WC Medicaid |
$21.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.08
|
| Rate for Payer: Ohio Health Group HMO |
$46.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.05
|
| Rate for Payer: PHCS Commercial |
$58.99
|
| Rate for Payer: United Healthcare All Payer |
$54.08
|
|
|
cloBAZam 5 MG/2 ML ORAL.SUSP
|
Facility
|
IP
|
$60.98
|
|
|
Service Code
|
NDC 67386031321
|
| Hospital Charge Code |
25004002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$58.54 |
| Rate for Payer: Aetna Commercial |
$46.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.56
|
| Rate for Payer: Cash Price |
$30.49
|
| Rate for Payer: Cigna Commercial |
$50.61
|
| Rate for Payer: First Health Commercial |
$57.93
|
| Rate for Payer: Humana Commercial |
$51.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.66
|
| Rate for Payer: Ohio Health Group HMO |
$45.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.90
|
| Rate for Payer: PHCS Commercial |
$58.54
|
| Rate for Payer: United Healthcare All Payer |
$53.66
|
|
|
cloBAZam 5 MG/2 ML ORAL.SUSP
|
Facility
|
OP
|
$60.98
|
|
|
Service Code
|
NDC 67386031321
|
| Hospital Charge Code |
25004002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$58.54 |
| Rate for Payer: Aetna Commercial |
$46.95
|
| Rate for Payer: Anthem Medicaid |
$20.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.56
|
| Rate for Payer: Cash Price |
$30.49
|
| Rate for Payer: Cigna Commercial |
$50.61
|
| Rate for Payer: First Health Commercial |
$57.93
|
| Rate for Payer: Humana Commercial |
$51.83
|
| Rate for Payer: Humana KY Medicaid |
$20.97
|
| Rate for Payer: Kentucky WC Medicaid |
$21.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.66
|
| Rate for Payer: Ohio Health Group HMO |
$45.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.90
|
| Rate for Payer: PHCS Commercial |
$58.54
|
| Rate for Payer: United Healthcare All Payer |
$53.66
|
|
|
CLOMID EQUIVALENT 50MG TABLET
|
Facility
|
IP
|
$9.87
|
|
|
Service Code
|
NDC 49884070155
|
| Hospital Charge Code |
25000436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.70
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna Commercial |
$8.19
|
| Rate for Payer: First Health Commercial |
$9.38
|
| Rate for Payer: Humana Commercial |
$8.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.69
|
| Rate for Payer: Ohio Health Group HMO |
$7.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$9.48
|
| Rate for Payer: United Healthcare All Payer |
$8.69
|
|
|
CLOMID EQUIVALENT 50MG TABLET
|
Facility
|
OP
|
$9.87
|
|
|
Service Code
|
NDC 49884070155
|
| Hospital Charge Code |
25000436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Anthem Medicaid |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.70
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna Commercial |
$8.19
|
| Rate for Payer: First Health Commercial |
$9.38
|
| Rate for Payer: Humana Commercial |
$8.39
|
| Rate for Payer: Humana KY Medicaid |
$3.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.69
|
| Rate for Payer: Ohio Health Group HMO |
$7.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$9.48
|
| Rate for Payer: United Healthcare All Payer |
$8.69
|
|
|
[C]LOMOTIL (DIPHENOX/ATR 1TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 406123601
|
| Hospital Charge Code |
25000073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
[C]LOMOTIL (DIPHENOX/ATR 1TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 406123601
|
| Hospital Charge Code |
25000073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
[C]LOMOTIL(DIPHENOXY/ATR)L 5ML
|
Facility
|
IP
|
$6.12
|
|
|
Service Code
|
NDC 54319446
|
| Hospital Charge Code |
25000104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna Commercial |
$4.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.77
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna Commercial |
$5.08
|
| Rate for Payer: First Health Commercial |
$5.81
|
| Rate for Payer: Humana Commercial |
$5.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.39
|
| Rate for Payer: Ohio Health Group HMO |
$4.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.90
|
| Rate for Payer: PHCS Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
[C]LOMOTIL(DIPHENOXY/ATR)L 5ML
|
Facility
|
OP
|
$6.12
|
|
|
Service Code
|
NDC 54319446
|
| Hospital Charge Code |
25000104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna Commercial |
$4.71
|
| Rate for Payer: Anthem Medicaid |
$2.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.77
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna Commercial |
$5.08
|
| Rate for Payer: First Health Commercial |
$5.81
|
| Rate for Payer: Humana Commercial |
$5.20
|
| Rate for Payer: Humana KY Medicaid |
$2.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.39
|
| Rate for Payer: Ohio Health Group HMO |
$4.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.90
|
| Rate for Payer: PHCS Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
CLONIDINE 20MCG/ML ORALS .5ML
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 68001023800
|
| Hospital Charge Code |
25002955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.79
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
CLONIDINE 20MCG/ML ORALS .5ML
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 68001023800
|
| Hospital Charge Code |
25002955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.79
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
CLOSED MANIP,KNEE W/OTH ANES
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS 27599
|
| Hospital Charge Code |
76102807
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
CLOSED MANIP,KNEE W/OTH ANES
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS 27599
|
| Hospital Charge Code |
76102807
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
CLOSED MANIP,KNEE W/OTH ANES
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 27599
|
| Hospital Charge Code |
76102807
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
CLOSED REDUC INTRPHLANG JNT
|
Facility
|
IP
|
$878.00
|
|
|
Service Code
|
HCPCS 28660
|
| Hospital Charge Code |
76101035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.14 |
| Max. Negotiated Rate |
$842.88 |
| Rate for Payer: First Health Commercial |
$834.10
|
| Rate for Payer: Humana Commercial |
$746.30
|
| Rate for Payer: Aetna Commercial |
$676.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$684.84
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cigna Commercial |
$728.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$719.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$647.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$263.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$772.64
|
| Rate for Payer: Ohio Health Group HMO |
$658.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$175.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.18
|
| Rate for Payer: PHCS Commercial |
$842.88
|
| Rate for Payer: United Healthcare All Payer |
$772.64
|
|
