|
AMBI PLATE SHORT BARREL 5H 130
|
Facility
|
IP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBI PLATE SHORT BARREL 5H 135
|
Facility
|
IP
|
$3,959.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.75 |
| Max. Negotiated Rate |
$3,801.24 |
| Rate for Payer: Aetna Commercial |
$3,048.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.50
|
| Rate for Payer: Cash Price |
$1,979.81
|
| Rate for Payer: Cigna Commercial |
$3,286.48
|
| Rate for Payer: First Health Commercial |
$3,761.64
|
| Rate for Payer: Humana Commercial |
$3,365.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,922.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.47
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,227.48
|
| Rate for Payer: PHCS Commercial |
$3,801.24
|
| Rate for Payer: United Healthcare All Payer |
$3,484.47
|
|
|
AMBI PLATE SHORT BARREL 5H 135
|
Facility
|
OP
|
$3,959.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.75 |
| Max. Negotiated Rate |
$3,801.24 |
| Rate for Payer: Aetna Commercial |
$3,048.91
|
| Rate for Payer: Anthem Medicaid |
$1,361.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.50
|
| Rate for Payer: Cash Price |
$1,979.81
|
| Rate for Payer: Cigna Commercial |
$3,286.48
|
| Rate for Payer: First Health Commercial |
$3,761.64
|
| Rate for Payer: Humana Commercial |
$3,365.68
|
| Rate for Payer: Humana KY Medicaid |
$1,361.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,375.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,922.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,389.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.47
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,227.48
|
| Rate for Payer: PHCS Commercial |
$3,801.24
|
| Rate for Payer: United Healthcare All Payer |
$3,484.47
|
|
|
AMBI PLATE SHORT BARREL 5H 140
|
Facility
|
IP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBI PLATE SHORT BARREL 5H 140
|
Facility
|
OP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem Medicaid |
$1,361.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Humana KY Medicaid |
$1,361.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,374.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,388.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBI PLATE SHORT BARREL 5H 145
|
Facility
|
OP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem Medicaid |
$1,361.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Humana KY Medicaid |
$1,361.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,374.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,388.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBI PLATE SHORT BARREL 5H 145
|
Facility
|
IP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBI PLATE SHORT BARREL 5H 150
|
Facility
|
IP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBI PLATE SHORT BARREL 5H 150
|
Facility
|
OP
|
$3,957.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.52 |
| Max. Negotiated Rate |
$3,799.56 |
| Rate for Payer: Aetna Commercial |
$3,047.57
|
| Rate for Payer: Anthem Medicaid |
$1,361.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,087.15
|
| Rate for Payer: Cash Price |
$1,978.94
|
| Rate for Payer: Cigna Commercial |
$3,285.04
|
| Rate for Payer: First Health Commercial |
$3,759.99
|
| Rate for Payer: Humana Commercial |
$3,364.20
|
| Rate for Payer: Humana KY Medicaid |
$1,361.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,374.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,245.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,920.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,388.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,482.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$791.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$514.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,226.94
|
| Rate for Payer: PHCS Commercial |
$3,799.56
|
| Rate for Payer: United Healthcare All Payer |
$3,482.93
|
|
|
AMBISOME 10MG [50MG VIAL]
|
Facility
|
IP
|
$1,684.27
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
25001860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$218.96 |
| Max. Negotiated Rate |
$1,616.90 |
| Rate for Payer: Aetna Commercial |
$1,296.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,313.73
|
| Rate for Payer: Cash Price |
$842.14
|
| Rate for Payer: Cigna Commercial |
$1,397.94
|
| Rate for Payer: First Health Commercial |
$1,600.06
|
| Rate for Payer: Humana Commercial |
$1,431.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,242.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$505.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$336.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$522.12
|
| Rate for Payer: PHCS Commercial |
$1,616.90
|
| Rate for Payer: United Healthcare All Payer |
$1,482.16
|
|
|
AMBISOME 10MG [50MG VIAL]
|
Facility
|
OP
|
$1,684.27
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
25001860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$1,616.90 |
| Rate for Payer: Aetna Commercial |
$1,296.89
|
| Rate for Payer: Anthem Medicaid |
$579.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$26.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,313.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$37.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.99
|
| Rate for Payer: Cash Price |
$842.14
|
| Rate for Payer: Cash Price |
$842.14
|
| Rate for Payer: Cigna Commercial |
$1,397.94
|
| Rate for Payer: First Health Commercial |
$1,600.06
|
| Rate for Payer: Humana Commercial |
$1,431.63
|
| Rate for Payer: Humana KY Medicaid |
$579.22
|
| Rate for Payer: Humana Medicare Advantage |
$26.66
|
| Rate for Payer: Kentucky WC Medicaid |
$585.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,242.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$590.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$336.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$522.12
|
| Rate for Payer: PHCS Commercial |
$1,616.90
|
| Rate for Payer: United Healthcare All Payer |
$1,482.16
|
|
|
AMICAR 1000 MG TABLET
|
Facility
|
OP
|
$80.96
|
|
|
Service Code
|
NDC 49411005130
|
| Hospital Charge Code |
25002821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.52 |
| Max. Negotiated Rate |
$77.72 |
| Rate for Payer: Aetna Commercial |
$62.34
|
| Rate for Payer: Anthem Medicaid |
$27.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.15
|
| Rate for Payer: Cash Price |
$40.48
|
| Rate for Payer: Cigna Commercial |
$67.20
|
| Rate for Payer: First Health Commercial |
$76.91
|
| Rate for Payer: Humana Commercial |
$68.82
|
| Rate for Payer: Humana KY Medicaid |
$27.84
|
| Rate for Payer: Kentucky WC Medicaid |
$28.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.24
|
| Rate for Payer: Ohio Health Group HMO |
$60.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.10
|
| Rate for Payer: PHCS Commercial |
$77.72
|
| Rate for Payer: United Healthcare All Payer |
$71.24
|
|
|
AMICAR 1000 MG TABLET
|
Facility
|
IP
|
$80.96
|
|
|
Service Code
|
NDC 49411005130
|
| Hospital Charge Code |
25002821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.52 |
| Max. Negotiated Rate |
$77.72 |
| Rate for Payer: Aetna Commercial |
$62.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.15
|
| Rate for Payer: Cash Price |
$40.48
|
| Rate for Payer: Cigna Commercial |
$67.20
|
| Rate for Payer: First Health Commercial |
$76.91
|
| Rate for Payer: Humana Commercial |
$68.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.24
|
| Rate for Payer: Ohio Health Group HMO |
$60.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.10
|
| Rate for Payer: PHCS Commercial |
$77.72
|
| Rate for Payer: United Healthcare All Payer |
$71.24
|
|
|
AMICAR(AMINOCACID)250MG/ML20ML
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
AMICAR(AMINOCACID)250MG/ML20ML
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
AMICAR(AMINOC ACID) 500MG TAB
|
Facility
|
OP
|
$28.89
|
|
|
Service Code
|
NDC 69315023103
|
| Hospital Charge Code |
25000208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$27.73 |
| Rate for Payer: Aetna Commercial |
$22.25
|
| Rate for Payer: Anthem Medicaid |
$9.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.53
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cigna Commercial |
$23.98
|
| Rate for Payer: First Health Commercial |
$27.45
|
| Rate for Payer: Humana Commercial |
$24.56
|
| Rate for Payer: Humana KY Medicaid |
$9.94
|
| Rate for Payer: Kentucky WC Medicaid |
$10.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.42
|
| Rate for Payer: Ohio Health Group HMO |
$21.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.96
|
| Rate for Payer: PHCS Commercial |
$27.73
|
| Rate for Payer: United Healthcare All Payer |
$25.42
|
|
|
AMICAR(AMINOC ACID) 500MG TAB
|
Facility
|
IP
|
$28.89
|
|
|
Service Code
|
NDC 69315023103
|
| Hospital Charge Code |
25000208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$27.73 |
| Rate for Payer: Aetna Commercial |
$22.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.53
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cigna Commercial |
$23.98
|
| Rate for Payer: First Health Commercial |
$27.45
|
| Rate for Payer: Humana Commercial |
$24.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.42
|
| Rate for Payer: Ohio Health Group HMO |
$21.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.96
|
| Rate for Payer: PHCS Commercial |
$27.73
|
| Rate for Payer: United Healthcare All Payer |
$25.42
|
|
|
AMIDATE (ETOMIDATE) 40MG/20ML
|
Facility
|
IP
|
$113.72
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002822
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$109.17 |
| Rate for Payer: Aetna Commercial |
$87.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.70
|
| Rate for Payer: Cash Price |
$56.86
|
| Rate for Payer: Cigna Commercial |
$94.39
|
| Rate for Payer: First Health Commercial |
$108.03
|
| Rate for Payer: Humana Commercial |
$96.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.07
|
| Rate for Payer: Ohio Health Group HMO |
$85.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.25
|
| Rate for Payer: PHCS Commercial |
$109.17
|
| Rate for Payer: United Healthcare All Payer |
$100.07
|
|
|
AMIDATE (ETOMIDATE) 40MG/20ML
|
Facility
|
OP
|
$113.72
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002822
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$109.17 |
| Rate for Payer: Aetna Commercial |
$87.56
|
| Rate for Payer: Anthem Medicaid |
$39.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.70
|
| Rate for Payer: Cash Price |
$56.86
|
| Rate for Payer: Cigna Commercial |
$94.39
|
| Rate for Payer: First Health Commercial |
$108.03
|
| Rate for Payer: Humana Commercial |
$96.66
|
| Rate for Payer: Humana KY Medicaid |
$39.11
|
| Rate for Payer: Kentucky WC Medicaid |
$39.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.07
|
| Rate for Payer: Ohio Health Group HMO |
$85.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.25
|
| Rate for Payer: PHCS Commercial |
$109.17
|
| Rate for Payer: United Healthcare All Payer |
$100.07
|
|
|
AMIKACIN [100 MG] 500MG/2ML VL
|
Facility
|
OP
|
$119.26
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
25001852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$114.49 |
| Rate for Payer: Aetna Commercial |
$91.83
|
| Rate for Payer: Anthem Medicaid |
$41.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.02
|
| Rate for Payer: Cash Price |
$59.63
|
| Rate for Payer: Cigna Commercial |
$98.99
|
| Rate for Payer: First Health Commercial |
$113.30
|
| Rate for Payer: Humana Commercial |
$101.37
|
| Rate for Payer: Humana KY Medicaid |
$41.01
|
| Rate for Payer: Kentucky WC Medicaid |
$41.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.95
|
| Rate for Payer: Ohio Health Group HMO |
$89.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.97
|
| Rate for Payer: PHCS Commercial |
$114.49
|
| Rate for Payer: United Healthcare All Payer |
$104.95
|
|
|
AMIKACIN [100 MG] 500MG/2ML VL
|
Facility
|
IP
|
$119.26
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
25001852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$114.49 |
| Rate for Payer: Aetna Commercial |
$91.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.02
|
| Rate for Payer: Cash Price |
$59.63
|
| Rate for Payer: Cigna Commercial |
$98.99
|
| Rate for Payer: First Health Commercial |
$113.30
|
| Rate for Payer: Humana Commercial |
$101.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.95
|
| Rate for Payer: Ohio Health Group HMO |
$89.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.97
|
| Rate for Payer: PHCS Commercial |
$114.49
|
| Rate for Payer: United Healthcare All Payer |
$104.95
|
|
|
AMILORIDE 5 MG TABLET
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 574029201
|
| Hospital Charge Code |
25000209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| 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 |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
AMILORIDE 5 MG TABLET
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 574029201
|
| Hospital Charge Code |
25000209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| 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 |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
AMINOACID 5%DEX 15%IV S 2000ML
|
Facility
|
IP
|
$218.40
|
|
|
Service Code
|
NDC 338109904
|
| Hospital Charge Code |
25002825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.39 |
| Max. Negotiated Rate |
$209.66 |
| Rate for Payer: Aetna Commercial |
$168.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.35
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$181.27
|
| Rate for Payer: First Health Commercial |
$207.48
|
| Rate for Payer: Humana Commercial |
$185.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.19
|
| Rate for Payer: Ohio Health Group HMO |
$163.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.70
|
| Rate for Payer: PHCS Commercial |
$209.66
|
| Rate for Payer: United Healthcare All Payer |
$192.19
|
|
|
AMINOACID 5%DEX 15%IV S 2000ML
|
Facility
|
OP
|
$218.40
|
|
|
Service Code
|
NDC 338109904
|
| Hospital Charge Code |
25002825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.39 |
| Max. Negotiated Rate |
$209.66 |
| Rate for Payer: Aetna Commercial |
$168.17
|
| Rate for Payer: Anthem Medicaid |
$75.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.35
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$181.27
|
| Rate for Payer: First Health Commercial |
$207.48
|
| Rate for Payer: Humana Commercial |
$185.64
|
| Rate for Payer: Humana KY Medicaid |
$75.11
|
| Rate for Payer: Kentucky WC Medicaid |
$75.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.19
|
| Rate for Payer: Ohio Health Group HMO |
$163.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.70
|
| Rate for Payer: PHCS Commercial |
$209.66
|
| Rate for Payer: United Healthcare All Payer |
$192.19
|
|
