|
NEORAL (CYCLOSPORINE 25MG/1CAP
|
Facility
|
IP
|
$9.10
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
25002503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
|
NEOSPORIN (BACI/NEO/POLY) 10ML
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
25001058
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.12
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna Commercial |
$1.19
|
| Rate for Payer: First Health Commercial |
$1.36
|
| Rate for Payer: Humana Commercial |
$1.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.26
|
| Rate for Payer: Ohio Health Group HMO |
$1.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.44
|
| Rate for Payer: PHCS Commercial |
$1.37
|
| Rate for Payer: United Healthcare All Payer |
$1.26
|
|
|
NEOSPORIN (BACI/NEO/POLY) 10ML
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
25001058
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Anthem Medicaid |
$0.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.12
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna Commercial |
$1.19
|
| Rate for Payer: First Health Commercial |
$1.36
|
| Rate for Payer: Humana Commercial |
$1.22
|
| Rate for Payer: Humana KY Medicaid |
$0.49
|
| Rate for Payer: Kentucky WC Medicaid |
$0.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.26
|
| Rate for Payer: Ohio Health Group HMO |
$1.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.44
|
| Rate for Payer: PHCS Commercial |
$1.37
|
| Rate for Payer: United Healthcare All Payer |
$1.26
|
|
|
NEOSPORIN(NEOMY/POLYMYXIN) 1ML
|
Facility
|
IP
|
$117.93
|
|
|
Service Code
|
NDC 39822120102
|
| Hospital Charge Code |
25001059
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$113.21 |
| Rate for Payer: Aetna Commercial |
$90.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.99
|
| Rate for Payer: Cash Price |
$58.97
|
| Rate for Payer: Cigna Commercial |
$97.88
|
| Rate for Payer: First Health Commercial |
$112.03
|
| Rate for Payer: Humana Commercial |
$100.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.78
|
| Rate for Payer: Ohio Health Group HMO |
$88.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.56
|
| Rate for Payer: PHCS Commercial |
$113.21
|
| Rate for Payer: United Healthcare All Payer |
$103.78
|
|
|
NEOSPORIN(NEOMY/POLYMYXIN) 1ML
|
Facility
|
OP
|
$117.93
|
|
|
Service Code
|
NDC 39822120102
|
| Hospital Charge Code |
25001059
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$113.21 |
| Rate for Payer: Aetna Commercial |
$90.81
|
| Rate for Payer: Anthem Medicaid |
$40.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.99
|
| Rate for Payer: Cash Price |
$58.97
|
| Rate for Payer: Cigna Commercial |
$97.88
|
| Rate for Payer: First Health Commercial |
$112.03
|
| Rate for Payer: Humana Commercial |
$100.24
|
| Rate for Payer: Humana KY Medicaid |
$40.56
|
| Rate for Payer: Kentucky WC Medicaid |
$40.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.78
|
| Rate for Payer: Ohio Health Group HMO |
$88.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.56
|
| Rate for Payer: PHCS Commercial |
$113.21
|
| Rate for Payer: United Healthcare All Payer |
$103.78
|
|
|
NEO-SYNEPHRINE 0.5% NASAL SPRY
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 225080547
|
| Hospital Charge Code |
25003731
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
NEO-SYNEPHRINE 0.5% NASAL SPRY
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 225080547
|
| Hospital Charge Code |
25003731
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
NEOSYNEPHRINE/PHENYLEP EA GTT
|
Facility
|
OP
|
$4.74
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
25001060
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
NEOSYNEPHRINE/PHENYLEP EA GTT
|
Facility
|
IP
|
$4.74
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
25001060
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
NEPHRINAX KIT
|
Facility
|
OP
|
$3,094.84
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$402.33 |
| Max. Negotiated Rate |
$2,971.05 |
| Rate for Payer: Aetna Commercial |
$2,383.03
|
| Rate for Payer: Anthem Medicaid |
$1,064.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,413.98
|
| Rate for Payer: Cash Price |
$1,547.42
|
| Rate for Payer: Cigna Commercial |
$2,568.72
|
| Rate for Payer: First Health Commercial |
$2,940.10
|
| Rate for Payer: Humana Commercial |
$2,630.61
|
| Rate for Payer: Humana KY Medicaid |
$1,064.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,075.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,537.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,283.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,085.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,723.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,321.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$618.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$402.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$959.40
|
| Rate for Payer: PHCS Commercial |
$2,971.05
|
| Rate for Payer: United Healthcare All Payer |
$2,723.46
|
|
|
NEPHRINAX KIT
|
Facility
|
IP
|
$3,094.84
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$402.33 |
| Max. Negotiated Rate |
$2,971.05 |
| Rate for Payer: Aetna Commercial |
$2,383.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,413.98
|
| Rate for Payer: Cash Price |
$1,547.42
|
| Rate for Payer: Cigna Commercial |
$2,568.72
|
| Rate for Payer: First Health Commercial |
$2,940.10
|
| Rate for Payer: Humana Commercial |
$2,630.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,537.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,283.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,723.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,321.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$618.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$402.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$959.40
|
| Rate for Payer: PHCS Commercial |
$2,971.05
|
| Rate for Payer: United Healthcare All Payer |
$2,723.46
|
|
|
NEPHROCAP (MULITPLE VITAMI 1EA
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 63044062201
|
| Hospital Charge Code |
25001061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| 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 |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
NEPHROCAP (MULITPLE VITAMI 1EA
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 63044062201
|
| Hospital Charge Code |
25001061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| 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 |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
NEPRO ENTERAL FEEDING 1000 ML
|
Facility
|
OP
|
$77.40
|
|
|
Service Code
|
NDC 70074062670
|
| Hospital Charge Code |
25003257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.30 |
| Rate for Payer: Aetna Commercial |
$59.60
|
| Rate for Payer: Anthem Medicaid |
$26.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$64.24
|
| Rate for Payer: First Health Commercial |
$73.53
|
| Rate for Payer: Humana Commercial |
$65.79
|
| Rate for Payer: Humana KY Medicaid |
$26.62
|
| Rate for Payer: Kentucky WC Medicaid |
$26.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.11
|
| Rate for Payer: Ohio Health Group HMO |
$58.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.99
|
| Rate for Payer: PHCS Commercial |
$74.30
|
| Rate for Payer: United Healthcare All Payer |
$68.11
|
|
|
NEPRO ENTERAL FEEDING 1000 ML
|
Facility
|
IP
|
$77.40
|
|
|
Service Code
|
NDC 70074062670
|
| Hospital Charge Code |
25003257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.30 |
| Rate for Payer: Aetna Commercial |
$59.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$64.24
|
| Rate for Payer: First Health Commercial |
$73.53
|
| Rate for Payer: Humana Commercial |
$65.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.11
|
| Rate for Payer: Ohio Health Group HMO |
$58.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.99
|
| Rate for Payer: PHCS Commercial |
$74.30
|
| Rate for Payer: United Healthcare All Payer |
$68.11
|
|
|
NEPTAZANE 50MG TABLET
|
Facility
|
OP
|
$12.60
|
|
|
Service Code
|
NDC 574079101
|
| Hospital Charge Code |
25001062
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$12.10 |
| Rate for Payer: Aetna Commercial |
$9.70
|
| Rate for Payer: Anthem Medicaid |
$4.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.83
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$10.46
|
| Rate for Payer: First Health Commercial |
$11.97
|
| Rate for Payer: Humana Commercial |
$10.71
|
| Rate for Payer: Humana KY Medicaid |
$4.33
|
| Rate for Payer: Kentucky WC Medicaid |
$4.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.09
|
| Rate for Payer: Ohio Health Group HMO |
$9.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.91
|
| Rate for Payer: PHCS Commercial |
$12.10
|
| Rate for Payer: United Healthcare All Payer |
$11.09
|
|
|
NEPTAZANE 50MG TABLET
|
Facility
|
IP
|
$12.60
|
|
|
Service Code
|
NDC 574079101
|
| Hospital Charge Code |
25001062
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$12.10 |
| Rate for Payer: Aetna Commercial |
$9.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.83
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$10.46
|
| Rate for Payer: First Health Commercial |
$11.97
|
| Rate for Payer: Humana Commercial |
$10.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.09
|
| Rate for Payer: Ohio Health Group HMO |
$9.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.91
|
| Rate for Payer: PHCS Commercial |
$12.10
|
| Rate for Payer: United Healthcare All Payer |
$11.09
|
|
|
NERVE GRAFT ARM/LEG <4 CM
|
Facility
|
IP
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64892
|
| Hospital Charge Code |
76102379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
NERVE GRAFT ARM/LEG <4 CM
|
Facility
|
OP
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64892
|
| Hospital Charge Code |
76102379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$8,064.71 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,760.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,064.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,776.69
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Humana Medicare Advantage |
$5,760.51
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,912.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
NERVE GRAFT ARM/LEG <4 CM
|
Professional
|
Both
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64892
|
| Hospital Charge Code |
76102379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$656.25 |
| Max. Negotiated Rate |
$1,875.00 |
| Rate for Payer: Aetna Commercial |
$1,699.30
|
| Rate for Payer: Anthem Medicaid |
$743.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,875.00
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,524.88
|
| Rate for Payer: Healthspan PPO |
$1,326.77
|
| Rate for Payer: Humana Medicaid |
$743.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,350.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$758.46
|
| Rate for Payer: Molina Healthcare Passport |
$743.59
|
| Rate for Payer: Multiplan PHCS |
$1,125.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,312.50
|
| Rate for Payer: UHCCP Medicaid |
$656.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$751.03
|
|
|
NERVE GRAFT ARM/LEG <4 CM(P
|
Professional
|
Both
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64892
|
| Hospital Charge Code |
761P2379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$656.25 |
| Max. Negotiated Rate |
$1,875.00 |
| Rate for Payer: Aetna Commercial |
$1,699.30
|
| Rate for Payer: Anthem Medicaid |
$743.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,875.00
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,524.88
|
| Rate for Payer: Healthspan PPO |
$1,326.77
|
| Rate for Payer: Humana Medicaid |
$743.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,350.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$758.46
|
| Rate for Payer: Molina Healthcare Passport |
$743.59
|
| Rate for Payer: Multiplan PHCS |
$1,125.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,312.50
|
| Rate for Payer: UHCCP Medicaid |
$656.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$751.03
|
|
|
NERVE GRAFT HAND/FOOT </4 CM
|
Facility
|
OP
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64890
|
| Hospital Charge Code |
76102378
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$8,064.71 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,760.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,064.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,776.69
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Humana Medicare Advantage |
$5,760.51
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,912.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
NERVE GRAFT HAND/FOOT </4 CM
|
Facility
|
IP
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64890
|
| Hospital Charge Code |
76102378
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
NERVE GRAFT HAND/FOOT </4 CM
|
Professional
|
Both
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64890
|
| Hospital Charge Code |
76102378
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$656.25 |
| Max. Negotiated Rate |
$1,875.00 |
| Rate for Payer: Aetna Commercial |
$1,737.46
|
| Rate for Payer: Anthem Medicaid |
$801.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,875.00
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,592.62
|
| Rate for Payer: Healthspan PPO |
$1,356.56
|
| Rate for Payer: Humana Medicaid |
$801.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,391.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$817.46
|
| Rate for Payer: Molina Healthcare Passport |
$801.43
|
| Rate for Payer: Multiplan PHCS |
$1,125.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,312.50
|
| Rate for Payer: UHCCP Medicaid |
$656.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$809.44
|
|
|
NERVE GRAFT HAND/FOOT </4 C(P
|
Professional
|
Both
|
$1,875.00
|
|
|
Service Code
|
HCPCS 64890
|
| Hospital Charge Code |
761P2378
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$656.25 |
| Max. Negotiated Rate |
$1,875.00 |
| Rate for Payer: Aetna Commercial |
$1,737.46
|
| Rate for Payer: Anthem Medicaid |
$801.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,875.00
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,592.62
|
| Rate for Payer: Healthspan PPO |
$1,356.56
|
| Rate for Payer: Humana Medicaid |
$801.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,391.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$817.46
|
| Rate for Payer: Molina Healthcare Passport |
$801.43
|
| Rate for Payer: Multiplan PHCS |
$1,125.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,312.50
|
| Rate for Payer: UHCCP Medicaid |
$656.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$809.44
|
|
