|
AMBISOME 10MG [50MG VIAL]
|
Facility
|
OP
|
$1,734.79
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
25001860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$1,665.40 |
| Rate for Payer: Aetna Commercial |
$1,335.79
|
| Rate for Payer: Anthem Medicaid |
$596.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,353.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.54
|
| Rate for Payer: Cash Price |
$867.40
|
| Rate for Payer: Cash Price |
$867.40
|
| Rate for Payer: Cigna Commercial |
$1,439.88
|
| Rate for Payer: First Health Commercial |
$1,648.05
|
| Rate for Payer: Humana Commercial |
$1,474.57
|
| Rate for Payer: Humana KY Medicaid |
$596.59
|
| Rate for Payer: Humana Medicare Advantage |
$22.62
|
| Rate for Payer: Kentucky WC Medicaid |
$602.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,422.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,280.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$608.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,526.62
|
| Rate for Payer: Ohio Health Group HMO |
$1,301.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,387.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,509.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,197.01
|
| Rate for Payer: PHCS Commercial |
$1,665.40
|
| Rate for Payer: United Healthcare All Payer |
$1,526.62
|
|
|
AMBISOME 10MG [50MG VIAL]
|
Facility
|
IP
|
$1,734.79
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
25001860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$520.44 |
| Max. Negotiated Rate |
$1,665.40 |
| Rate for Payer: Aetna Commercial |
$1,335.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,353.14
|
| Rate for Payer: Cash Price |
$867.40
|
| Rate for Payer: Cigna Commercial |
$1,439.88
|
| Rate for Payer: First Health Commercial |
$1,648.05
|
| Rate for Payer: Humana Commercial |
$1,474.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,422.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,280.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$520.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,526.62
|
| Rate for Payer: Ohio Health Group HMO |
$1,301.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,387.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,509.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,197.01
|
| Rate for Payer: PHCS Commercial |
$1,665.40
|
| Rate for Payer: United Healthcare All Payer |
$1,526.62
|
|
|
AMICAR 1000 MG TABLET
|
Facility
|
IP
|
$80.96
|
|
|
Service Code
|
NDC 49411005130
|
| Hospital Charge Code |
25002821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.29 |
| 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 |
$64.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.86
|
| Rate for Payer: PHCS Commercial |
$77.72
|
| Rate for Payer: United Healthcare All Payer |
$71.24
|
|
|
AMICAR 1000 MG TABLET
|
Facility
|
OP
|
$80.96
|
|
|
Service Code
|
NDC 49411005130
|
| Hospital Charge Code |
25002821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.29 |
| 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 |
$64.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.86
|
| Rate for Payer: PHCS Commercial |
$77.72
|
| Rate for Payer: United Healthcare All Payer |
$71.24
|
|
|
AMICAR(AMINOCACID)1G(5GVIAL)
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
25002820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| 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 |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
AMICAR(AMINOCACID)1G(5GVIAL)
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
25002820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| 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 |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
AMICAR(AMINOC ACID) 500MG TAB
|
Facility
|
IP
|
$28.89
|
|
|
Service Code
|
NDC 69315023103
|
| Hospital Charge Code |
25000208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.67 |
| 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 |
$23.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.93
|
| Rate for Payer: PHCS Commercial |
$27.73
|
| Rate for Payer: United Healthcare All Payer |
$25.42
|
|
|
AMICAR(AMINOC ACID) 500MG TAB
|
Facility
|
OP
|
$28.89
|
|
|
Service Code
|
NDC 69315023103
|
| Hospital Charge Code |
25000208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.67 |
| 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 |
$23.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.93
|
| Rate for Payer: PHCS Commercial |
$27.73
|
| Rate for Payer: United Healthcare All Payer |
$25.42
|
|
|
AMIDATE (ETOMIDATE) 40MG/20ML
|
Facility
|
OP
|
$113.72
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002822
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$34.12 |
| 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 |
$90.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.47
|
| Rate for Payer: PHCS Commercial |
$109.17
|
| Rate for Payer: United Healthcare All Payer |
$100.07
|
|
|
AMIDATE (ETOMIDATE) 40MG/20ML
|
Facility
|
IP
|
$113.72
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002822
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$34.12 |
| 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 |
$90.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.47
|
| 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 |
$35.78 |
| 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 |
$95.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.29
|
| 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 |
$35.78 |
| 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 |
$95.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.29
|
| Rate for Payer: PHCS Commercial |
$114.49
|
| Rate for Payer: United Healthcare All Payer |
$104.95
|
|
|
AMILORIDE 5 MG TABLET
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 574029201
|
| Hospital Charge Code |
25000209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
AMILORIDE 5 MG TABLET
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 574029201
|
| Hospital Charge Code |
25000209
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| 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: 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| 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 |
$65.52 |
| 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 |
$174.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.70
|
| 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 |
$65.52 |
| 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 |
$174.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.70
|
| Rate for Payer: PHCS Commercial |
$209.66
|
| Rate for Payer: United Healthcare All Payer |
$192.19
|
|
|
AMINOACID 5% DEX 15% S 1000ML
|
Facility
|
IP
|
$107.98
|
|
|
Service Code
|
NDC 338113703
|
| Hospital Charge Code |
25002824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.39 |
| Max. Negotiated Rate |
$103.66 |
| Rate for Payer: Aetna Commercial |
$83.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.22
|
| Rate for Payer: Cash Price |
$53.99
|
| Rate for Payer: Cigna Commercial |
$89.62
|
| Rate for Payer: First Health Commercial |
$102.58
|
| Rate for Payer: Humana Commercial |
$91.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.02
|
| Rate for Payer: Ohio Health Group HMO |
$80.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.51
|
| Rate for Payer: PHCS Commercial |
$103.66
|
| Rate for Payer: United Healthcare All Payer |
$95.02
|
|
|
AMINOACID 5% DEX 15% S 1000ML
|
Facility
|
OP
|
$107.98
|
|
|
Service Code
|
NDC 338113703
|
| Hospital Charge Code |
25002824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.39 |
| Max. Negotiated Rate |
$103.66 |
| Rate for Payer: Aetna Commercial |
$83.14
|
| Rate for Payer: Anthem Medicaid |
$37.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.22
|
| Rate for Payer: Cash Price |
$53.99
|
| Rate for Payer: Cigna Commercial |
$89.62
|
| Rate for Payer: First Health Commercial |
$102.58
|
| Rate for Payer: Humana Commercial |
$91.78
|
| Rate for Payer: Humana KY Medicaid |
$37.13
|
| Rate for Payer: Kentucky WC Medicaid |
$37.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.02
|
| Rate for Payer: Ohio Health Group HMO |
$80.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.51
|
| Rate for Payer: PHCS Commercial |
$103.66
|
| Rate for Payer: United Healthcare All Payer |
$95.02
|
|
|
AMINOPHYLLINE 500MG/20ML
|
Facility
|
OP
|
$116.21
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
25002827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$111.56 |
| Rate for Payer: Aetna Commercial |
$89.48
|
| Rate for Payer: Anthem Medicaid |
$39.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.64
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: Cigna Commercial |
$96.45
|
| Rate for Payer: First Health Commercial |
$110.40
|
| Rate for Payer: Humana Commercial |
$98.78
|
| Rate for Payer: Humana KY Medicaid |
$39.96
|
| Rate for Payer: Kentucky WC Medicaid |
$40.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.26
|
| Rate for Payer: Ohio Health Group HMO |
$87.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.18
|
| Rate for Payer: PHCS Commercial |
$111.56
|
| Rate for Payer: United Healthcare All Payer |
$102.26
|
|
|
AMINOPHYLLINE 500MG/20ML
|
Facility
|
IP
|
$116.21
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
25002827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$111.56 |
| Rate for Payer: Aetna Commercial |
$89.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.64
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: Cigna Commercial |
$96.45
|
| Rate for Payer: First Health Commercial |
$110.40
|
| Rate for Payer: Humana Commercial |
$98.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.26
|
| Rate for Payer: Ohio Health Group HMO |
$87.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.18
|
| Rate for Payer: PHCS Commercial |
$111.56
|
| Rate for Payer: United Healthcare All Payer |
$102.26
|
|
|
AMINOPHYLLINE (THEOPH)
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
30000049
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem Medicaid |
$14.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.14
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Humana KY Medicaid |
$14.14
|
| Rate for Payer: Humana Medicare Advantage |
$14.14
|
| Rate for Payer: Kentucky WC Medicaid |
$14.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.11
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
AMINOPHYLLINE (THEOPH)
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
30000049
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.56
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.11
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
AMINOSYN II 10% 500ML
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
NDC 990717217
|
| Hospital Charge Code |
25002828
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$191.04 |
| Rate for Payer: Aetna Commercial |
$153.23
|
| Rate for Payer: Anthem Medicaid |
$68.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.22
|
| Rate for Payer: Cash Price |
$99.50
|
| Rate for Payer: Cigna Commercial |
$165.17
|
| Rate for Payer: First Health Commercial |
$189.05
|
| Rate for Payer: Humana Commercial |
$169.15
|
| Rate for Payer: Humana KY Medicaid |
$68.44
|
| Rate for Payer: Kentucky WC Medicaid |
$69.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.12
|
| Rate for Payer: Ohio Health Group HMO |
$149.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.31
|
| Rate for Payer: PHCS Commercial |
$191.04
|
| Rate for Payer: United Healthcare All Payer |
$175.12
|
|
|
AMINOSYN II 10% 500ML
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
NDC 990717217
|
| Hospital Charge Code |
25002828
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$191.04 |
| Rate for Payer: Aetna Commercial |
$153.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.22
|
| Rate for Payer: Cash Price |
$99.50
|
| Rate for Payer: Cigna Commercial |
$165.17
|
| Rate for Payer: First Health Commercial |
$189.05
|
| Rate for Payer: Humana Commercial |
$169.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.12
|
| Rate for Payer: Ohio Health Group HMO |
$149.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.31
|
| Rate for Payer: PHCS Commercial |
$191.04
|
| Rate for Payer: United Healthcare All Payer |
$175.12
|
|
|
AMINOSYN II 15% IV SOLU 2000ML
|
Facility
|
OP
|
$323.68
|
|
|
Service Code
|
NDC 990717117
|
| Hospital Charge Code |
25002829
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$97.10 |
| Max. Negotiated Rate |
$310.73 |
| Rate for Payer: Aetna Commercial |
$249.23
|
| Rate for Payer: Anthem Medicaid |
$111.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$252.47
|
| Rate for Payer: Cash Price |
$161.84
|
| Rate for Payer: Cigna Commercial |
$268.65
|
| Rate for Payer: First Health Commercial |
$307.50
|
| Rate for Payer: Humana Commercial |
$275.13
|
| Rate for Payer: Humana KY Medicaid |
$111.31
|
| Rate for Payer: Kentucky WC Medicaid |
$112.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.84
|
| Rate for Payer: Ohio Health Group HMO |
$242.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.34
|
| Rate for Payer: PHCS Commercial |
$310.73
|
| Rate for Payer: United Healthcare All Payer |
$284.84
|
|
