|
DIAPHYSEAL OSS SEG 3CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 3CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 5CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 5CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 7CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 7CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 9CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 9CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIASTAT 2.5 MG KIT
|
Facility
|
OP
|
$315.75
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
25002405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.72 |
| Max. Negotiated Rate |
$303.12 |
| Rate for Payer: Aetna Commercial |
$243.13
|
| Rate for Payer: Anthem Medicaid |
$108.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$246.28
|
| Rate for Payer: Cash Price |
$157.88
|
| Rate for Payer: Cigna Commercial |
$262.07
|
| Rate for Payer: First Health Commercial |
$299.96
|
| Rate for Payer: Humana Commercial |
$268.39
|
| Rate for Payer: Humana KY Medicaid |
$108.59
|
| Rate for Payer: Kentucky WC Medicaid |
$109.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$258.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$233.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$110.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$277.86
|
| Rate for Payer: Ohio Health Group HMO |
$236.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$274.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.87
|
| Rate for Payer: PHCS Commercial |
$303.12
|
| Rate for Payer: United Healthcare All Payer |
$277.86
|
|
|
DIASTAT 2.5 MG KIT
|
Facility
|
IP
|
$315.75
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
25002405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.72 |
| Max. Negotiated Rate |
$303.12 |
| Rate for Payer: Aetna Commercial |
$243.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$246.28
|
| Rate for Payer: Cash Price |
$157.88
|
| Rate for Payer: Cigna Commercial |
$262.07
|
| Rate for Payer: First Health Commercial |
$299.96
|
| Rate for Payer: Humana Commercial |
$268.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$258.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$233.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$277.86
|
| Rate for Payer: Ohio Health Group HMO |
$236.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$274.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.87
|
| Rate for Payer: PHCS Commercial |
$303.12
|
| Rate for Payer: United Healthcare All Payer |
$277.86
|
|
|
DIASTAT ACUDIAL 5 7.5 10MGRECG
|
Facility
|
OP
|
$363.38
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
25002406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.01 |
| Max. Negotiated Rate |
$348.84 |
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Anthem Medicaid |
$124.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$283.44
|
| Rate for Payer: Cash Price |
$181.69
|
| Rate for Payer: Cigna Commercial |
$301.61
|
| Rate for Payer: First Health Commercial |
$345.21
|
| Rate for Payer: Humana Commercial |
$308.87
|
| Rate for Payer: Humana KY Medicaid |
$124.97
|
| Rate for Payer: Kentucky WC Medicaid |
$126.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$268.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.77
|
| Rate for Payer: Ohio Health Group HMO |
$272.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$290.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$250.73
|
| Rate for Payer: PHCS Commercial |
$348.84
|
| Rate for Payer: United Healthcare All Payer |
$319.77
|
|
|
DIASTAT ACUDIAL 5 7.5 10MGRECG
|
Facility
|
IP
|
$363.38
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
25002406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.01 |
| Max. Negotiated Rate |
$348.84 |
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$283.44
|
| Rate for Payer: Cash Price |
$181.69
|
| Rate for Payer: Cigna Commercial |
$301.61
|
| Rate for Payer: First Health Commercial |
$345.21
|
| Rate for Payer: Humana Commercial |
$308.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$268.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.77
|
| Rate for Payer: Ohio Health Group HMO |
$272.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$290.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$250.73
|
| Rate for Payer: PHCS Commercial |
$348.84
|
| Rate for Payer: United Healthcare All Payer |
$319.77
|
|
|
DIATHERMY TREATMENT
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS 97024
|
| Hospital Charge Code |
42000059
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$12.90 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.54
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.67
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
DIATHERMY TREATMENT
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS 97024
|
| Hospital Charge Code |
42000059
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$12.90 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem Medicaid |
$14.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.54
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Humana KY Medicaid |
$14.79
|
| Rate for Payer: Kentucky WC Medicaid |
$14.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.67
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
DICLOFENAC 1.3% 5 Patch/Pkg
|
Facility
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 59762070702
|
| Hospital Charge Code |
25004025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$14.46 |
| Rate for Payer: Aetna Commercial |
$11.60
|
| Rate for Payer: Anthem Medicaid |
$5.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11.75
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Cigna Commercial |
$12.50
|
| Rate for Payer: First Health Commercial |
$14.31
|
| Rate for Payer: Humana Commercial |
$12.80
|
| Rate for Payer: Humana KY Medicaid |
$5.18
|
| Rate for Payer: Kentucky WC Medicaid |
$5.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.25
|
| Rate for Payer: Ohio Health Group HMO |
$11.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.39
|
| Rate for Payer: PHCS Commercial |
$14.46
|
| Rate for Payer: United Healthcare All Payer |
$13.25
|
|
|
DICLOFENAC 1.3% 5 Patch/Pkg
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 59762070702
|
| Hospital Charge Code |
25004025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$14.46 |
| Rate for Payer: Aetna Commercial |
$11.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11.75
|
| Rate for Payer: Cash Price |
$7.53
|
| Rate for Payer: Cigna Commercial |
$12.50
|
| Rate for Payer: First Health Commercial |
$14.31
|
| Rate for Payer: Humana Commercial |
$12.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.25
|
| Rate for Payer: Ohio Health Group HMO |
$11.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.39
|
| Rate for Payer: PHCS Commercial |
$14.46
|
| Rate for Payer: United Healthcare All Payer |
$13.25
|
|
|
DICLOXACILLIN 250MG CAPSULE
|
Facility
|
OP
|
$4.88
|
|
|
Service Code
|
NDC 93312301
|
| Hospital Charge Code |
25000555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DICLOXACILLIN 250MG CAPSULE
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
NDC 93312301
|
| Hospital Charge Code |
25000555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DICLOXACILLIN 500MG CAPSULE
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 93312501
|
| Hospital Charge Code |
25000556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.78
|
| Rate for Payer: First Health Commercial |
$8.90
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.25
|
| Rate for Payer: Ohio Health Group HMO |
$7.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.47
|
| Rate for Payer: PHCS Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Payer |
$8.25
|
|
|
DICLOXACILLIN 500MG CAPSULE
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 93312501
|
| Hospital Charge Code |
25000556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem Medicaid |
$3.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.78
|
| Rate for Payer: First Health Commercial |
$8.90
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Humana KY Medicaid |
$3.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.25
|
| Rate for Payer: Ohio Health Group HMO |
$7.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.47
|
| Rate for Payer: PHCS Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Payer |
$8.25
|
|
|
DIFFERENTIAL ADSORPTION SERUM
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 86978
|
| Hospital Charge Code |
30001244
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.68
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
DIFFERENTIAL ADSORPTION SERUM
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 86978
|
| Hospital Charge Code |
30001244
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$54.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.88
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$54.88
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$55.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
Dificid 200mg/5mL Susp 5mL
|
Facility
|
OP
|
$362.78
|
|
|
Service Code
|
NDC 52015070022
|
| Hospital Charge Code |
25004135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.83 |
| Max. Negotiated Rate |
$348.27 |
| Rate for Payer: Aetna Commercial |
$279.34
|
| Rate for Payer: Anthem Medicaid |
$124.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.97
|
| Rate for Payer: Cash Price |
$181.39
|
| Rate for Payer: Cigna Commercial |
$301.11
|
| Rate for Payer: First Health Commercial |
$344.64
|
| Rate for Payer: Humana Commercial |
$308.36
|
| Rate for Payer: Humana KY Medicaid |
$124.76
|
| Rate for Payer: Kentucky WC Medicaid |
$126.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.25
|
| Rate for Payer: Ohio Health Group HMO |
$272.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$290.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$315.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$250.32
|
| Rate for Payer: PHCS Commercial |
$348.27
|
| Rate for Payer: United Healthcare All Payer |
$319.25
|
|
|
Dificid 200mg/5mL Susp 5mL
|
Facility
|
IP
|
$362.78
|
|
|
Service Code
|
NDC 52015070022
|
| Hospital Charge Code |
25004135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.83 |
| Max. Negotiated Rate |
$348.27 |
| Rate for Payer: Aetna Commercial |
$279.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.97
|
| Rate for Payer: Cash Price |
$181.39
|
| Rate for Payer: Cigna Commercial |
$301.11
|
| Rate for Payer: First Health Commercial |
$344.64
|
| Rate for Payer: Humana Commercial |
$308.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.25
|
| Rate for Payer: Ohio Health Group HMO |
$272.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$290.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$315.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$250.32
|
| Rate for Payer: PHCS Commercial |
$348.27
|
| Rate for Payer: United Healthcare All Payer |
$319.25
|
|
|
DIFICID 200MG TABLET
|
Facility
|
OP
|
$430.25
|
|
|
Service Code
|
NDC 52015008001
|
| Hospital Charge Code |
25000558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.07 |
| Max. Negotiated Rate |
$413.04 |
| Rate for Payer: Aetna Commercial |
$331.29
|
| Rate for Payer: Anthem Medicaid |
$147.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.60
|
| Rate for Payer: Cash Price |
$215.12
|
| Rate for Payer: Cigna Commercial |
$357.11
|
| Rate for Payer: First Health Commercial |
$408.74
|
| Rate for Payer: Humana Commercial |
$365.71
|
| Rate for Payer: Humana KY Medicaid |
$147.96
|
| Rate for Payer: Kentucky WC Medicaid |
$149.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.62
|
| Rate for Payer: Ohio Health Group HMO |
$322.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.87
|
| Rate for Payer: PHCS Commercial |
$413.04
|
| Rate for Payer: United Healthcare All Payer |
$378.62
|
|
