DIL FEM URT WSUPP/INSTLJ SBSQ
|
Professional
|
Both
|
$531.00
|
|
Service Code
|
HCPCS 53661
|
Hospital Charge Code |
76102121
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$24.42 |
Max. Negotiated Rate |
$531.00 |
Rate for Payer: Aetna Commercial |
$66.53
|
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.42
|
Rate for Payer: Anthem Medicaid |
$25.21
|
Rate for Payer: Buckeye Medicare Advantage |
$531.00
|
Rate for Payer: Cash Price |
$265.50
|
Rate for Payer: Cash Price |
$265.50
|
Rate for Payer: Cigna Commercial |
$112.90
|
Rate for Payer: Healthspan PPO |
$91.71
|
Rate for Payer: Humana Medicaid |
$25.21
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.05
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.71
|
Rate for Payer: Molina Healthcare Passport |
$25.21
|
Rate for Payer: Multiplan PHCS |
$318.60
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$371.70
|
Rate for Payer: UHCCP Medicaid |
$25.64
|
Rate for Payer: Wellcare CHIP/Medicaid |
$25.46
|
|
DIL FEM URT WSUPP/INSTLJ SBS(T
|
Facility
|
OP
|
$156.00
|
|
Service Code
|
HCPCS 53661
|
Hospital Charge Code |
761T2121
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$20.28 |
Max. Negotiated Rate |
$154.64 |
Rate for Payer: Aetna Commercial |
$120.12
|
Rate for Payer: Anthem Medicaid |
$53.65
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
Rate for Payer: Anthem POS/PPO/Traditional |
$121.68
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
Rate for Payer: Cash Price |
$78.00
|
Rate for Payer: Cash Price |
$78.00
|
Rate for Payer: Cigna Commercial |
$129.48
|
Rate for Payer: First Health Commercial |
$148.20
|
Rate for Payer: Humana Commercial |
$132.60
|
Rate for Payer: Humana KY Medicaid |
$53.65
|
Rate for Payer: Humana Medicare Advantage |
$110.46
|
Rate for Payer: Kentucky WC Medicaid |
$54.19
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
Rate for Payer: Molina Healthcare Medicaid |
$54.72
|
Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
Rate for Payer: Ohio Health Group HMO |
$117.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$31.20
|
Rate for Payer: Ohio Health Group PPO No Differential |
$20.28
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.36
|
Rate for Payer: PHCS Commercial |
$149.76
|
Rate for Payer: United Healthcare All Payer |
$137.28
|
|
DIL FEM URT WSUPP/INSTLJ SBS(T
|
Facility
|
IP
|
$156.00
|
|
Service Code
|
HCPCS 53661
|
Hospital Charge Code |
761T2121
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$20.28 |
Max. Negotiated Rate |
$149.76 |
Rate for Payer: Aetna Commercial |
$120.12
|
Rate for Payer: Anthem POS/PPO/Traditional |
$121.68
|
Rate for Payer: Cash Price |
$78.00
|
Rate for Payer: Cigna Commercial |
$129.48
|
Rate for Payer: First Health Commercial |
$148.20
|
Rate for Payer: Humana Commercial |
$132.60
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
Rate for Payer: Ohio Health Group HMO |
$117.00
|
Rate for Payer: Ohio Health Group PPO Differential |
$31.20
|
Rate for Payer: Ohio Health Group PPO No Differential |
$20.28
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.36
|
Rate for Payer: PHCS Commercial |
$149.76
|
Rate for Payer: United Healthcare All Payer |
$137.28
|
|
DILTIAZEM 50MG/10ML VIAL
|
Facility
|
OP
|
$79.90
|
|
Service Code
|
NDC 641601401
|
Hospital Charge Code |
25003022
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$10.39 |
Max. Negotiated Rate |
$76.70 |
Rate for Payer: Aetna Commercial |
$61.52
|
Rate for Payer: Anthem Medicaid |
$27.48
|
Rate for Payer: Anthem POS/PPO/Traditional |
$62.32
|
Rate for Payer: Cash Price |
$39.95
|
Rate for Payer: Cigna Commercial |
$66.32
|
Rate for Payer: First Health Commercial |
$75.90
|
Rate for Payer: Humana Commercial |
$67.92
|
Rate for Payer: Humana KY Medicaid |
$27.48
|
Rate for Payer: Kentucky WC Medicaid |
$27.76
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$65.52
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.97
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$23.97
|
Rate for Payer: Molina Healthcare Medicaid |
$28.03
|
Rate for Payer: Ohio Health Choice Commercial |
$70.31
|
Rate for Payer: Ohio Health Group HMO |
$59.92
|
Rate for Payer: Ohio Health Group PPO Differential |
$15.98
|
Rate for Payer: Ohio Health Group PPO No Differential |
$10.39
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.77
|
Rate for Payer: PHCS Commercial |
$76.70
|
Rate for Payer: United Healthcare All Payer |
$70.31
|
|
DILTIAZEM 50MG/10ML VIAL
|
Facility
|
IP
|
$79.90
|
|
Service Code
|
NDC 641601401
|
Hospital Charge Code |
25003022
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$10.39 |
Max. Negotiated Rate |
$76.70 |
Rate for Payer: Aetna Commercial |
$61.52
|
Rate for Payer: Anthem POS/PPO/Traditional |
$62.32
|
Rate for Payer: Cash Price |
$39.95
|
Rate for Payer: Cigna Commercial |
$66.32
|
Rate for Payer: First Health Commercial |
$75.90
|
Rate for Payer: Humana Commercial |
$67.92
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$65.52
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.97
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$23.97
|
Rate for Payer: Ohio Health Choice Commercial |
$70.31
|
Rate for Payer: Ohio Health Group HMO |
$59.92
|
Rate for Payer: Ohio Health Group PPO Differential |
$15.98
|
Rate for Payer: Ohio Health Group PPO No Differential |
$10.39
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.77
|
Rate for Payer: PHCS Commercial |
$76.70
|
Rate for Payer: United Healthcare All Payer |
$70.31
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Professional
|
Both
|
$5,352.50
|
|
Service Code
|
HCPCS 53605
|
Hospital Charge Code |
76102118
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$51.11 |
Max. Negotiated Rate |
$5,352.50 |
Rate for Payer: Aetna Commercial |
$107.61
|
Rate for Payer: Anthem Medicaid |
$51.11
|
Rate for Payer: Buckeye Medicare Advantage |
$5,352.50
|
Rate for Payer: Cash Price |
$2,676.25
|
Rate for Payer: Cash Price |
$2,676.25
|
Rate for Payer: Cigna Commercial |
$97.27
|
Rate for Payer: Healthspan PPO |
$86.04
|
Rate for Payer: Humana Medicaid |
$51.11
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.08
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.13
|
Rate for Payer: Molina Healthcare Passport |
$51.11
|
Rate for Payer: Multiplan PHCS |
$3,211.50
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,746.75
|
Rate for Payer: UHCCP Medicaid |
$1,873.38
|
Rate for Payer: Wellcare CHIP/Medicaid |
$51.62
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
OP
|
$5,352.50
|
|
Service Code
|
HCPCS 53605
|
Hospital Charge Code |
76102118
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$695.82 |
Max. Negotiated Rate |
$5,138.40 |
Rate for Payer: Aetna Commercial |
$4,121.42
|
Rate for Payer: Anthem Medicaid |
$1,840.72
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,174.95
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
Rate for Payer: Cash Price |
$2,676.25
|
Rate for Payer: Cash Price |
$2,676.25
|
Rate for Payer: Cigna Commercial |
$4,442.58
|
Rate for Payer: First Health Commercial |
$5,084.88
|
Rate for Payer: Humana Commercial |
$4,549.62
|
Rate for Payer: Humana KY Medicaid |
$1,840.72
|
Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
Rate for Payer: Kentucky WC Medicaid |
$1,859.46
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,389.05
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,950.14
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
Rate for Payer: Molina Healthcare Medicaid |
$1,877.66
|
Rate for Payer: Ohio Health Choice Commercial |
$4,710.20
|
Rate for Payer: Ohio Health Group HMO |
$4,014.38
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,070.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$695.82
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,659.28
|
Rate for Payer: PHCS Commercial |
$5,138.40
|
Rate for Payer: United Healthcare All Payer |
$4,710.20
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
IP
|
$5,352.50
|
|
Service Code
|
HCPCS 53605
|
Hospital Charge Code |
76102118
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$695.82 |
Max. Negotiated Rate |
$5,138.40 |
Rate for Payer: Aetna Commercial |
$4,121.42
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,174.95
|
Rate for Payer: Cash Price |
$2,676.25
|
Rate for Payer: Cigna Commercial |
$4,442.58
|
Rate for Payer: First Health Commercial |
$5,084.88
|
Rate for Payer: Humana Commercial |
$4,549.62
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,389.05
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,950.14
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.75
|
Rate for Payer: Ohio Health Choice Commercial |
$4,710.20
|
Rate for Payer: Ohio Health Group HMO |
$4,014.38
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,070.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$695.82
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,659.28
|
Rate for Payer: PHCS Commercial |
$5,138.40
|
Rate for Payer: United Healthcare All Payer |
$4,710.20
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
OP
|
$5,087.50
|
|
Service Code
|
HCPCS 53605
|
Hospital Charge Code |
761T2118
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$661.38 |
Max. Negotiated Rate |
$4,884.00 |
Rate for Payer: Aetna Commercial |
$3,917.38
|
Rate for Payer: Anthem Medicaid |
$1,749.59
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
Rate for Payer: Cash Price |
$2,543.75
|
Rate for Payer: Cash Price |
$2,543.75
|
Rate for Payer: Cigna Commercial |
$4,222.62
|
Rate for Payer: First Health Commercial |
$4,833.12
|
Rate for Payer: Humana Commercial |
$4,324.38
|
Rate for Payer: Humana KY Medicaid |
$1,749.59
|
Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
Rate for Payer: Kentucky WC Medicaid |
$1,767.40
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
Rate for Payer: Molina Healthcare Medicaid |
$1,784.70
|
Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
Rate for Payer: PHCS Commercial |
$4,884.00
|
Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Professional
|
Both
|
$265.00
|
|
Service Code
|
HCPCS 53605
|
Hospital Charge Code |
761P2118
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$51.11 |
Max. Negotiated Rate |
$265.00 |
Rate for Payer: Aetna Commercial |
$107.61
|
Rate for Payer: Anthem Medicaid |
$51.11
|
Rate for Payer: Buckeye Medicare Advantage |
$265.00
|
Rate for Payer: Cash Price |
$132.50
|
Rate for Payer: Cash Price |
$132.50
|
Rate for Payer: Cigna Commercial |
$97.27
|
Rate for Payer: Healthspan PPO |
$86.04
|
Rate for Payer: Humana Medicaid |
$51.11
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.08
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.13
|
Rate for Payer: Molina Healthcare Passport |
$51.11
|
Rate for Payer: Multiplan PHCS |
$159.00
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$185.50
|
Rate for Payer: UHCCP Medicaid |
$92.75
|
Rate for Payer: Wellcare CHIP/Medicaid |
$51.62
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
IP
|
$5,087.50
|
|
Service Code
|
HCPCS 53605
|
Hospital Charge Code |
761T2118
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$661.38 |
Max. Negotiated Rate |
$4,884.00 |
Rate for Payer: Aetna Commercial |
$3,917.38
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
Rate for Payer: Cash Price |
$2,543.75
|
Rate for Payer: Cigna Commercial |
$4,222.62
|
Rate for Payer: First Health Commercial |
$4,833.12
|
Rate for Payer: Humana Commercial |
$4,324.38
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
Rate for Payer: PHCS Commercial |
$4,884.00
|
Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
OP
|
$2,472.47
|
|
Service Code
|
HCPCS 53620
|
Hospital Charge Code |
76102119
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$321.42 |
Max. Negotiated Rate |
$2,373.57 |
Rate for Payer: Aetna Commercial |
$1,903.80
|
Rate for Payer: Anthem Medicaid |
$850.28
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,928.53
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
Rate for Payer: Cash Price |
$1,236.23
|
Rate for Payer: Cash Price |
$1,236.23
|
Rate for Payer: Cigna Commercial |
$2,052.15
|
Rate for Payer: First Health Commercial |
$2,348.85
|
Rate for Payer: Humana Commercial |
$2,101.60
|
Rate for Payer: Humana KY Medicaid |
$850.28
|
Rate for Payer: Humana Medicare Advantage |
$590.72
|
Rate for Payer: Kentucky WC Medicaid |
$858.94
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$2,027.43
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,824.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
Rate for Payer: Molina Healthcare Medicaid |
$867.34
|
Rate for Payer: Ohio Health Choice Commercial |
$2,175.77
|
Rate for Payer: Ohio Health Group HMO |
$1,854.35
|
Rate for Payer: Ohio Health Group PPO Differential |
$494.49
|
Rate for Payer: Ohio Health Group PPO No Differential |
$321.42
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$766.47
|
Rate for Payer: PHCS Commercial |
$2,373.57
|
Rate for Payer: United Healthcare All Payer |
$2,175.77
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Professional
|
Both
|
$2,472.47
|
|
Service Code
|
HCPCS 53620
|
Hospital Charge Code |
76102119
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$55.05 |
Max. Negotiated Rate |
$2,472.47 |
Rate for Payer: Aetna Commercial |
$144.71
|
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$55.47
|
Rate for Payer: Anthem Medicaid |
$55.05
|
Rate for Payer: Buckeye Medicare Advantage |
$2,472.47
|
Rate for Payer: Cash Price |
$1,236.23
|
Rate for Payer: Cash Price |
$1,236.23
|
Rate for Payer: Cigna Commercial |
$198.31
|
Rate for Payer: Healthspan PPO |
$158.08
|
Rate for Payer: Humana Medicaid |
$55.05
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.73
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.15
|
Rate for Payer: Molina Healthcare Passport |
$55.05
|
Rate for Payer: Multiplan PHCS |
$1,483.48
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,730.73
|
Rate for Payer: UHCCP Medicaid |
$58.24
|
Rate for Payer: Wellcare CHIP/Medicaid |
$55.60
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
IP
|
$1,972.47
|
|
Service Code
|
HCPCS 53620
|
Hospital Charge Code |
761T2119
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$256.42 |
Max. Negotiated Rate |
$1,893.57 |
Rate for Payer: Aetna Commercial |
$1,518.80
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,538.53
|
Rate for Payer: Cash Price |
$986.24
|
Rate for Payer: Cigna Commercial |
$1,637.15
|
Rate for Payer: First Health Commercial |
$1,873.85
|
Rate for Payer: Humana Commercial |
$1,676.60
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$1,617.43
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,455.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$591.74
|
Rate for Payer: Ohio Health Choice Commercial |
$1,735.77
|
Rate for Payer: Ohio Health Group HMO |
$1,479.35
|
Rate for Payer: Ohio Health Group PPO Differential |
$394.49
|
Rate for Payer: Ohio Health Group PPO No Differential |
$256.42
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$611.47
|
Rate for Payer: PHCS Commercial |
$1,893.57
|
Rate for Payer: United Healthcare All Payer |
$1,735.77
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
IP
|
$2,472.47
|
|
Service Code
|
HCPCS 53620
|
Hospital Charge Code |
76102119
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$321.42 |
Max. Negotiated Rate |
$2,373.57 |
Rate for Payer: Aetna Commercial |
$1,903.80
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,928.53
|
Rate for Payer: Cash Price |
$1,236.23
|
Rate for Payer: Cigna Commercial |
$2,052.15
|
Rate for Payer: First Health Commercial |
$2,348.85
|
Rate for Payer: Humana Commercial |
$2,101.60
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$2,027.43
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,824.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$741.74
|
Rate for Payer: Ohio Health Choice Commercial |
$2,175.77
|
Rate for Payer: Ohio Health Group HMO |
$1,854.35
|
Rate for Payer: Ohio Health Group PPO Differential |
$494.49
|
Rate for Payer: Ohio Health Group PPO No Differential |
$321.42
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$766.47
|
Rate for Payer: PHCS Commercial |
$2,373.57
|
Rate for Payer: United Healthcare All Payer |
$2,175.77
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
OP
|
$1,972.47
|
|
Service Code
|
HCPCS 53620
|
Hospital Charge Code |
761T2119
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$256.42 |
Max. Negotiated Rate |
$1,893.57 |
Rate for Payer: Aetna Commercial |
$1,518.80
|
Rate for Payer: Anthem Medicaid |
$678.33
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
Rate for Payer: Anthem POS/PPO/Traditional |
$1,538.53
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
Rate for Payer: Cash Price |
$986.24
|
Rate for Payer: Cash Price |
$986.24
|
Rate for Payer: Cigna Commercial |
$1,637.15
|
Rate for Payer: First Health Commercial |
$1,873.85
|
Rate for Payer: Humana Commercial |
$1,676.60
|
Rate for Payer: Humana KY Medicaid |
$678.33
|
Rate for Payer: Humana Medicare Advantage |
$590.72
|
Rate for Payer: Kentucky WC Medicaid |
$685.24
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$1,617.43
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,455.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
Rate for Payer: Molina Healthcare Medicaid |
$691.94
|
Rate for Payer: Ohio Health Choice Commercial |
$1,735.77
|
Rate for Payer: Ohio Health Group HMO |
$1,479.35
|
Rate for Payer: Ohio Health Group PPO Differential |
$394.49
|
Rate for Payer: Ohio Health Group PPO No Differential |
$256.42
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$611.47
|
Rate for Payer: PHCS Commercial |
$1,893.57
|
Rate for Payer: United Healthcare All Payer |
$1,735.77
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Professional
|
Both
|
$500.00
|
|
Service Code
|
HCPCS 53620
|
Hospital Charge Code |
761P2119
|
Hospital Revenue Code
|
761
|
Min. Negotiated Rate |
$55.05 |
Max. Negotiated Rate |
$500.00 |
Rate for Payer: Aetna Commercial |
$144.71
|
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$55.47
|
Rate for Payer: Anthem Medicaid |
$55.05
|
Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
Rate for Payer: Cash Price |
$250.00
|
Rate for Payer: Cash Price |
$250.00
|
Rate for Payer: Cigna Commercial |
$198.31
|
Rate for Payer: Healthspan PPO |
$158.08
|
Rate for Payer: Humana Medicaid |
$55.05
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.73
|
Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.15
|
Rate for Payer: Molina Healthcare Passport |
$55.05
|
Rate for Payer: Multiplan PHCS |
$300.00
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
Rate for Payer: UHCCP Medicaid |
$58.24
|
Rate for Payer: Wellcare CHIP/Medicaid |
$55.60
|
|
DIMETHICONE 12.5% CREAM 118mL
|
Facility
|
IP
|
$3.42
|
|
Service Code
|
NDC 53329002144
|
Hospital Charge Code |
25004442
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.44 |
Max. Negotiated Rate |
$3.28 |
Rate for Payer: Aetna Commercial |
$2.63
|
Rate for Payer: Anthem POS/PPO/Traditional |
$2.67
|
Rate for Payer: Cash Price |
$1.71
|
Rate for Payer: Cigna Commercial |
$2.84
|
Rate for Payer: First Health Commercial |
$3.25
|
Rate for Payer: Humana Commercial |
$2.91
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$2.80
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.52
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.03
|
Rate for Payer: Ohio Health Choice Commercial |
$3.01
|
Rate for Payer: Ohio Health Group HMO |
$2.56
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.68
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.44
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.06
|
Rate for Payer: PHCS Commercial |
$3.28
|
Rate for Payer: United Healthcare All Payer |
$3.01
|
|
DIMETHICONE 12.5% CREAM 118mL
|
Facility
|
OP
|
$3.42
|
|
Service Code
|
NDC 53329002144
|
Hospital Charge Code |
25004442
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.44 |
Max. Negotiated Rate |
$3.28 |
Rate for Payer: Aetna Commercial |
$2.63
|
Rate for Payer: Anthem Medicaid |
$1.18
|
Rate for Payer: Anthem POS/PPO/Traditional |
$2.67
|
Rate for Payer: Cash Price |
$1.71
|
Rate for Payer: Cigna Commercial |
$2.84
|
Rate for Payer: First Health Commercial |
$3.25
|
Rate for Payer: Humana Commercial |
$2.91
|
Rate for Payer: Humana KY Medicaid |
$1.18
|
Rate for Payer: Kentucky WC Medicaid |
$1.19
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$2.80
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.52
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.03
|
Rate for Payer: Molina Healthcare Medicaid |
$1.20
|
Rate for Payer: Ohio Health Choice Commercial |
$3.01
|
Rate for Payer: Ohio Health Group HMO |
$2.56
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.68
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.44
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.06
|
Rate for Payer: PHCS Commercial |
$3.28
|
Rate for Payer: United Healthcare All Payer |
$3.01
|
|
DIOVAN 40 MG TABLET
|
Facility
|
IP
|
$4.47
|
|
Service Code
|
NDC 378580793
|
Hospital Charge Code |
25000568
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.58 |
Max. Negotiated Rate |
$4.29 |
Rate for Payer: Aetna Commercial |
$3.44
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
Rate for Payer: Cash Price |
$2.23
|
Rate for Payer: Cigna Commercial |
$3.71
|
Rate for Payer: First Health Commercial |
$4.25
|
Rate for Payer: Humana Commercial |
$3.80
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
Rate for Payer: Ohio Health Group HMO |
$3.35
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
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 |
$4.29
|
Rate for Payer: United Healthcare All Payer |
$3.93
|
|
DIOVAN 40 MG TABLET
|
Facility
|
OP
|
$4.47
|
|
Service Code
|
NDC 378580793
|
Hospital Charge Code |
25000568
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.58 |
Max. Negotiated Rate |
$4.29 |
Rate for Payer: Aetna Commercial |
$3.44
|
Rate for Payer: Anthem Medicaid |
$1.54
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
Rate for Payer: Cash Price |
$2.23
|
Rate for Payer: Cigna Commercial |
$3.71
|
Rate for Payer: First Health Commercial |
$4.25
|
Rate for Payer: Humana Commercial |
$3.80
|
Rate for Payer: Humana KY Medicaid |
$1.54
|
Rate for Payer: Kentucky WC Medicaid |
$1.55
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
Rate for Payer: Ohio Health Group HMO |
$3.35
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
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 |
$4.29
|
Rate for Payer: United Healthcare All Payer |
$3.93
|
|
DIOVAN 80MG TABLET
|
Facility
|
OP
|
$4.53
|
|
Service Code
|
NDC 378581377
|
Hospital Charge Code |
25000569
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.59 |
Max. Negotiated Rate |
$4.35 |
Rate for Payer: Aetna Commercial |
$3.49
|
Rate for Payer: Anthem Medicaid |
$1.56
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
Rate for Payer: Cash Price |
$2.27
|
Rate for Payer: Cigna Commercial |
$3.76
|
Rate for Payer: First Health Commercial |
$4.30
|
Rate for Payer: Humana Commercial |
$3.85
|
Rate for Payer: Humana KY Medicaid |
$1.56
|
Rate for Payer: Kentucky WC Medicaid |
$1.57
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
Rate for Payer: Ohio Health Group HMO |
$3.40
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
Rate for Payer: PHCS Commercial |
$4.35
|
Rate for Payer: United Healthcare All Payer |
$3.99
|
|
DIOVAN 80MG TABLET
|
Facility
|
IP
|
$4.53
|
|
Service Code
|
NDC 378581377
|
Hospital Charge Code |
25000569
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.59 |
Max. Negotiated Rate |
$4.35 |
Rate for Payer: Aetna Commercial |
$3.49
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
Rate for Payer: Cash Price |
$2.27
|
Rate for Payer: Cigna Commercial |
$3.76
|
Rate for Payer: First Health Commercial |
$4.30
|
Rate for Payer: Humana Commercial |
$3.85
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
Rate for Payer: Ohio Health Group HMO |
$3.40
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
Rate for Payer: PHCS Commercial |
$4.35
|
Rate for Payer: United Healthcare All Payer |
$3.99
|
|
Diphenhydramine 1% Crm 28gm
|
Facility
|
OP
|
$0.13
|
|
Service Code
|
NDC 12547017162
|
Hospital Charge Code |
25000314
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.12 |
Rate for Payer: Humana Commercial |
$0.11
|
Rate for Payer: Humana KY Medicaid |
$0.04
|
Rate for Payer: Kentucky WC Medicaid |
$0.05
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$0.11
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.10
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
Rate for Payer: Molina Healthcare Medicaid |
$0.05
|
Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
Rate for Payer: Ohio Health Group HMO |
$0.10
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
Rate for Payer: PHCS Commercial |
$0.12
|
Rate for Payer: United Healthcare All Payer |
$0.11
|
Rate for Payer: Aetna Commercial |
$0.10
|
Rate for Payer: Anthem Medicaid |
$0.04
|
Rate for Payer: Anthem POS/PPO/Traditional |
$0.10
|
Rate for Payer: Cash Price |
$0.06
|
Rate for Payer: Cigna Commercial |
$0.11
|
Rate for Payer: First Health Commercial |
$0.12
|
|
Diphenhydramine 1% Crm 28gm
|
Facility
|
IP
|
$0.13
|
|
Service Code
|
NDC 12547017162
|
Hospital Charge Code |
25000314
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.12 |
Rate for Payer: Aetna Commercial |
$0.10
|
Rate for Payer: Anthem POS/PPO/Traditional |
$0.10
|
Rate for Payer: Cash Price |
$0.06
|
Rate for Payer: Cigna Commercial |
$0.11
|
Rate for Payer: First Health Commercial |
$0.12
|
Rate for Payer: Humana Commercial |
$0.11
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$0.11
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.10
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
Rate for Payer: Ohio Health Group HMO |
$0.10
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
Rate for Payer: PHCS Commercial |
$0.12
|
Rate for Payer: United Healthcare All Payer |
$0.11
|
|