|
AMNION MATRIX- THIN 4*8
|
Facility
|
OP
|
$17,610.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,289.30 |
| Max. Negotiated Rate |
$16,905.60 |
| Rate for Payer: Aetna Commercial |
$13,559.70
|
| Rate for Payer: Anthem Medicaid |
$6,056.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,735.80
|
| Rate for Payer: Cash Price |
$8,805.00
|
| Rate for Payer: Cigna Commercial |
$14,616.30
|
| Rate for Payer: First Health Commercial |
$16,729.50
|
| Rate for Payer: Humana Commercial |
$14,968.50
|
| Rate for Payer: Humana KY Medicaid |
$6,056.08
|
| Rate for Payer: Kentucky WC Medicaid |
$6,117.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,440.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,996.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,283.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,177.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,496.80
|
| Rate for Payer: Ohio Health Group HMO |
$13,207.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,522.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,289.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,459.10
|
| Rate for Payer: PHCS Commercial |
$16,905.60
|
| Rate for Payer: United Healthcare All Payer |
$15,496.80
|
|
|
AMNION MATRIX- THIN 7*7
|
Facility
|
OP
|
$22,776.25
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,960.91 |
| Max. Negotiated Rate |
$21,865.20 |
| Rate for Payer: Aetna Commercial |
$17,537.71
|
| Rate for Payer: Anthem Medicaid |
$7,832.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,765.48
|
| Rate for Payer: Cash Price |
$11,388.12
|
| Rate for Payer: Cigna Commercial |
$18,904.29
|
| Rate for Payer: First Health Commercial |
$21,637.44
|
| Rate for Payer: Humana Commercial |
$19,359.81
|
| Rate for Payer: Humana KY Medicaid |
$7,832.75
|
| Rate for Payer: Kentucky WC Medicaid |
$7,912.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,676.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,808.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,832.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,989.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,043.10
|
| Rate for Payer: Ohio Health Group HMO |
$17,082.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,555.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,960.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,060.64
|
| Rate for Payer: PHCS Commercial |
$21,865.20
|
| Rate for Payer: United Healthcare All Payer |
$20,043.10
|
|
|
AMNION MATRIX- THIN 7*7
|
Facility
|
IP
|
$22,776.25
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,960.91 |
| Max. Negotiated Rate |
$21,865.20 |
| Rate for Payer: Aetna Commercial |
$17,537.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,765.48
|
| Rate for Payer: Cash Price |
$11,388.12
|
| Rate for Payer: Cigna Commercial |
$18,904.29
|
| Rate for Payer: First Health Commercial |
$21,637.44
|
| Rate for Payer: Humana Commercial |
$19,359.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,676.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,808.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,832.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,043.10
|
| Rate for Payer: Ohio Health Group HMO |
$17,082.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,555.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,960.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,060.64
|
| Rate for Payer: PHCS Commercial |
$21,865.20
|
| Rate for Payer: United Healthcare All Payer |
$20,043.10
|
|
|
AMOXICILLIN 250 MG 250MG/1CAP
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 781202001
|
| Hospital Charge Code |
25000214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
AMOXICILLIN 250 MG 250MG/1CAP
|
Facility
|
OP
|
$4.31
|
|
|
Service Code
|
NDC 781202001
|
| Hospital Charge Code |
25000214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
AMOXICILLIN 250MG/5ML LIQ
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 143988901
|
| Hospital Charge Code |
25000216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
AMOXICILLIN 250MG/5ML LIQ
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 143988901
|
| Hospital Charge Code |
25000216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
AMOXICILLIN 875 TABLET
|
Facility
|
OP
|
$4.85
|
|
|
Service Code
|
NDC 93226401
|
| Hospital Charge Code |
25000218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
AMOXICILLIN 875 TABLET
|
Facility
|
IP
|
$4.85
|
|
|
Service Code
|
NDC 93226401
|
| Hospital Charge Code |
25000218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLA(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
761P0757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.70 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$909.55
|
| Rate for Payer: Anthem Medicaid |
$300.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,112.78
|
| Rate for Payer: Healthspan PPO |
$823.86
|
| Rate for Payer: Humana Medicaid |
$300.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$783.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.71
|
| Rate for Payer: Molina Healthcare Passport |
$300.70
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.71
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
76100757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
IP
|
$4,088.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
45000150
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$531.44 |
| Max. Negotiated Rate |
$3,924.48 |
| Rate for Payer: Aetna Commercial |
$3,147.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.64
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cigna Commercial |
$3,393.04
|
| Rate for Payer: First Health Commercial |
$3,883.60
|
| Rate for Payer: Humana Commercial |
$3,474.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,016.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,226.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.28
|
| Rate for Payer: PHCS Commercial |
$3,924.48
|
| Rate for Payer: United Healthcare All Payer |
$3,597.44
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
76100757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
OP
|
$4,088.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
45000150
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$531.44 |
| Max. Negotiated Rate |
$3,924.48 |
| Rate for Payer: Aetna Commercial |
$3,147.76
|
| Rate for Payer: Anthem Medicaid |
$1,405.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cigna Commercial |
$3,393.04
|
| Rate for Payer: First Health Commercial |
$3,883.60
|
| Rate for Payer: Humana Commercial |
$3,474.80
|
| Rate for Payer: Humana KY Medicaid |
$1,405.86
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,420.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,016.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,434.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.28
|
| Rate for Payer: PHCS Commercial |
$3,924.48
|
| Rate for Payer: United Healthcare All Payer |
$3,597.44
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
76100757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.70 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$909.55
|
| Rate for Payer: Anthem Medicaid |
$300.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,112.78
|
| Rate for Payer: Healthspan PPO |
$823.86
|
| Rate for Payer: Humana Medicaid |
$300.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$783.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.71
|
| Rate for Payer: Molina Healthcare Passport |
$300.70
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.71
|
|
|
AMPICILLIN 1GM IVPB PREMIX
|
Facility
|
IP
|
$113.30
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25003882
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$108.77 |
| Rate for Payer: Aetna Commercial |
$87.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.37
|
| Rate for Payer: Cash Price |
$56.65
|
| Rate for Payer: Cigna Commercial |
$94.04
|
| Rate for Payer: First Health Commercial |
$107.64
|
| Rate for Payer: Humana Commercial |
$96.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.70
|
| Rate for Payer: Ohio Health Group HMO |
$84.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.12
|
| Rate for Payer: PHCS Commercial |
$108.77
|
| Rate for Payer: United Healthcare All Payer |
$99.70
|
|
|
AMPICILLIN 1GM IVPB PREMIX
|
Facility
|
OP
|
$113.30
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25003882
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$108.77 |
| Rate for Payer: Aetna Commercial |
$87.24
|
| Rate for Payer: Anthem Medicaid |
$38.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.37
|
| Rate for Payer: Cash Price |
$56.65
|
| Rate for Payer: Cigna Commercial |
$94.04
|
| Rate for Payer: First Health Commercial |
$107.64
|
| Rate for Payer: Humana Commercial |
$96.30
|
| Rate for Payer: Humana KY Medicaid |
$38.96
|
| Rate for Payer: Kentucky WC Medicaid |
$39.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.70
|
| Rate for Payer: Ohio Health Group HMO |
$84.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.12
|
| Rate for Payer: PHCS Commercial |
$108.77
|
| Rate for Payer: United Healthcare All Payer |
$99.70
|
|
|
AMPICILLIN 500MG (1000MG SDV)
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$77.62 |
| Rate for Payer: Aetna Commercial |
$62.25
|
| Rate for Payer: Anthem Medicaid |
$27.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.06
|
| Rate for Payer: Cash Price |
$40.42
|
| Rate for Payer: Cigna Commercial |
$67.11
|
| Rate for Payer: First Health Commercial |
$76.81
|
| Rate for Payer: Humana Commercial |
$68.72
|
| Rate for Payer: Humana KY Medicaid |
$27.80
|
| Rate for Payer: Kentucky WC Medicaid |
$28.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.15
|
| Rate for Payer: Ohio Health Group HMO |
$60.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.06
|
| Rate for Payer: PHCS Commercial |
$77.62
|
| Rate for Payer: United Healthcare All Payer |
$71.15
|
|
|
AMPICILLIN 500MG (1000MG SDV)
|
Facility
|
IP
|
$80.85
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$77.62 |
| Rate for Payer: Aetna Commercial |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.06
|
| Rate for Payer: Cash Price |
$40.42
|
| Rate for Payer: Cigna Commercial |
$67.11
|
| Rate for Payer: First Health Commercial |
$76.81
|
| Rate for Payer: Humana Commercial |
$68.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.15
|
| Rate for Payer: Ohio Health Group HMO |
$60.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.06
|
| Rate for Payer: PHCS Commercial |
$77.62
|
| Rate for Payer: United Healthcare All Payer |
$71.15
|
|
|
AMPICILLIN 500MG (500MG SDV)
|
Facility
|
IP
|
$78.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$75.67 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.48
|
| Rate for Payer: Cash Price |
$39.41
|
| Rate for Payer: Cigna Commercial |
$65.42
|
| Rate for Payer: First Health Commercial |
$74.88
|
| Rate for Payer: Humana Commercial |
$67.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.43
|
| Rate for Payer: PHCS Commercial |
$75.67
|
| Rate for Payer: United Healthcare All Payer |
$69.36
|
|
|
AMPICILLIN 500MG (500MG SDV)
|
Facility
|
OP
|
$78.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$75.67 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Anthem Medicaid |
$27.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.48
|
| Rate for Payer: Cash Price |
$39.41
|
| Rate for Payer: Cigna Commercial |
$65.42
|
| Rate for Payer: First Health Commercial |
$74.88
|
| Rate for Payer: Humana Commercial |
$67.00
|
| Rate for Payer: Humana KY Medicaid |
$27.11
|
| Rate for Payer: Kentucky WC Medicaid |
$27.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.43
|
| Rate for Payer: PHCS Commercial |
$75.67
|
| Rate for Payer: United Healthcare All Payer |
$69.36
|
|
|
AMPICILLIN IV 500mg(2gm/20mL)
|
Facility
|
OP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25004194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem Medicaid |
$39.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.40
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Humana KY Medicaid |
$39.24
|
| Rate for Payer: Kentucky WC Medicaid |
$39.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.37
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPICILLIN IV 500mg(2gm/20mL)
|
Facility
|
IP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25004194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.40
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.37
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPICILLIN IV 500MG(2GM/8ML)
|
Facility
|
IP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.40
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.37
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPICILLIN IV 500MG(2GM/8ML)
|
Facility
|
OP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem Medicaid |
$39.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.40
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Humana KY Medicaid |
$39.24
|
| Rate for Payer: Kentucky WC Medicaid |
$39.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.37
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
