|
NEUROMEND 12MM*5.0CM
|
Facility
|
OP
|
$8,318.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,081.44 |
| Max. Negotiated Rate |
$7,986.05 |
| Rate for Payer: Aetna Commercial |
$6,405.48
|
| Rate for Payer: Anthem Medicaid |
$2,860.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,488.66
|
| Rate for Payer: Cash Price |
$4,159.40
|
| Rate for Payer: Cigna Commercial |
$6,904.60
|
| Rate for Payer: First Health Commercial |
$7,902.86
|
| Rate for Payer: Humana Commercial |
$7,070.98
|
| Rate for Payer: Humana KY Medicaid |
$2,860.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,889.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,821.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,139.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,495.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,918.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,320.54
|
| Rate for Payer: Ohio Health Group HMO |
$6,239.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,663.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,081.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,578.83
|
| Rate for Payer: PHCS Commercial |
$7,986.05
|
| Rate for Payer: United Healthcare All Payer |
$7,320.54
|
|
|
NEUROMEND 4MM*2.5CM
|
Facility
|
IP
|
$7,880.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,024.50 |
| Max. Negotiated Rate |
$7,565.57 |
| Rate for Payer: Aetna Commercial |
$6,068.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,147.02
|
| Rate for Payer: Cash Price |
$3,940.40
|
| Rate for Payer: Cigna Commercial |
$6,541.06
|
| Rate for Payer: First Health Commercial |
$7,486.76
|
| Rate for Payer: Humana Commercial |
$6,698.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,462.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,816.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,364.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,935.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,910.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,576.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,024.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,443.05
|
| Rate for Payer: PHCS Commercial |
$7,565.57
|
| Rate for Payer: United Healthcare All Payer |
$6,935.10
|
|
|
NEUROMEND 4MM*2.5CM
|
Facility
|
OP
|
$7,880.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,024.50 |
| Max. Negotiated Rate |
$7,565.57 |
| Rate for Payer: Aetna Commercial |
$6,068.22
|
| Rate for Payer: Anthem Medicaid |
$2,710.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,147.02
|
| Rate for Payer: Cash Price |
$3,940.40
|
| Rate for Payer: Cigna Commercial |
$6,541.06
|
| Rate for Payer: First Health Commercial |
$7,486.76
|
| Rate for Payer: Humana Commercial |
$6,698.68
|
| Rate for Payer: Humana KY Medicaid |
$2,710.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,737.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,462.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,816.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,364.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,764.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,935.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,910.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,576.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,024.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,443.05
|
| Rate for Payer: PHCS Commercial |
$7,565.57
|
| Rate for Payer: United Healthcare All Payer |
$6,935.10
|
|
|
NEUROMEND 4MM*5.0CM
|
Facility
|
OP
|
$8,318.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,081.44 |
| Max. Negotiated Rate |
$7,986.05 |
| Rate for Payer: Aetna Commercial |
$6,405.48
|
| Rate for Payer: Anthem Medicaid |
$2,860.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,488.66
|
| Rate for Payer: Cash Price |
$4,159.40
|
| Rate for Payer: Cigna Commercial |
$6,904.60
|
| Rate for Payer: First Health Commercial |
$7,902.86
|
| Rate for Payer: Humana Commercial |
$7,070.98
|
| Rate for Payer: Humana KY Medicaid |
$2,860.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,889.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,821.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,139.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,495.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,918.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,320.54
|
| Rate for Payer: Ohio Health Group HMO |
$6,239.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,663.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,081.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,578.83
|
| Rate for Payer: PHCS Commercial |
$7,986.05
|
| Rate for Payer: United Healthcare All Payer |
$7,320.54
|
|
|
NEUROMEND 4MM*5.0CM
|
Facility
|
IP
|
$8,318.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,081.44 |
| Max. Negotiated Rate |
$7,986.05 |
| Rate for Payer: Aetna Commercial |
$6,405.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,488.66
|
| Rate for Payer: Cash Price |
$4,159.40
|
| Rate for Payer: Cigna Commercial |
$6,904.60
|
| Rate for Payer: First Health Commercial |
$7,902.86
|
| Rate for Payer: Humana Commercial |
$7,070.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,821.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,139.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,495.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,320.54
|
| Rate for Payer: Ohio Health Group HMO |
$6,239.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,663.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,081.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,578.83
|
| Rate for Payer: PHCS Commercial |
$7,986.05
|
| Rate for Payer: United Healthcare All Payer |
$7,320.54
|
|
|
NEUROMEND 6MM*2.5CM
|
Facility
|
OP
|
$8,092.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,052.02 |
| Max. Negotiated Rate |
$7,768.80 |
| Rate for Payer: Aetna Commercial |
$6,231.22
|
| Rate for Payer: Anthem Medicaid |
$2,783.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,312.15
|
| Rate for Payer: Cash Price |
$4,046.25
|
| Rate for Payer: Cigna Commercial |
$6,716.78
|
| Rate for Payer: First Health Commercial |
$7,687.88
|
| Rate for Payer: Humana Commercial |
$6,878.62
|
| Rate for Payer: Humana KY Medicaid |
$2,783.01
|
| Rate for Payer: Kentucky WC Medicaid |
$2,811.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,635.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,972.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,427.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,838.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,121.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,069.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,618.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,052.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,508.68
|
| Rate for Payer: PHCS Commercial |
$7,768.80
|
| Rate for Payer: United Healthcare All Payer |
$7,121.40
|
|
|
NEUROMEND 6MM*2.5CM
|
Facility
|
IP
|
$8,092.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,052.02 |
| Max. Negotiated Rate |
$7,768.80 |
| Rate for Payer: Aetna Commercial |
$6,231.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,312.15
|
| Rate for Payer: Cash Price |
$4,046.25
|
| Rate for Payer: Cigna Commercial |
$6,716.78
|
| Rate for Payer: First Health Commercial |
$7,687.88
|
| Rate for Payer: Humana Commercial |
$6,878.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,635.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,972.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,427.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,121.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,069.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,618.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,052.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,508.68
|
| Rate for Payer: PHCS Commercial |
$7,768.80
|
| Rate for Payer: United Healthcare All Payer |
$7,121.40
|
|
|
NEUROMEND 6MM*5.0CM
|
Facility
|
IP
|
$8,548.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,111.34 |
| Max. Negotiated Rate |
$8,206.80 |
| Rate for Payer: Aetna Commercial |
$6,582.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,668.02
|
| Rate for Payer: Cash Price |
$4,274.38
|
| Rate for Payer: Cigna Commercial |
$7,095.46
|
| Rate for Payer: First Health Commercial |
$8,121.31
|
| Rate for Payer: Humana Commercial |
$7,266.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,009.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,308.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,564.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,522.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,709.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,111.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,650.11
|
| Rate for Payer: PHCS Commercial |
$8,206.80
|
| Rate for Payer: United Healthcare All Payer |
$7,522.90
|
|
|
NEUROMEND 6MM*5.0CM
|
Facility
|
OP
|
$8,548.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,111.34 |
| Max. Negotiated Rate |
$8,206.80 |
| Rate for Payer: Aetna Commercial |
$6,582.54
|
| Rate for Payer: Anthem Medicaid |
$2,939.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,668.02
|
| Rate for Payer: Cash Price |
$4,274.38
|
| Rate for Payer: Cigna Commercial |
$7,095.46
|
| Rate for Payer: First Health Commercial |
$8,121.31
|
| Rate for Payer: Humana Commercial |
$7,266.44
|
| Rate for Payer: Humana KY Medicaid |
$2,939.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,969.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,009.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,308.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,564.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,998.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,522.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,709.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,111.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,650.11
|
| Rate for Payer: PHCS Commercial |
$8,206.80
|
| Rate for Payer: United Healthcare All Payer |
$7,522.90
|
|
|
NEUROMUCULAR RE ED 15 MIN 1
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
42000018
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem Medicaid |
$45.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.96
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Humana KY Medicaid |
$45.39
|
| Rate for Payer: Kentucky WC Medicaid |
$45.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
NEUROMUCULAR RE ED 15 MIN 1
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
42000018
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.96
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
NEURON SPECIFIC ENOLASE, S
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
30001824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem Medicaid |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.27
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Humana KY Medicaid |
$17.27
|
| Rate for Payer: Humana Medicare Advantage |
$17.27
|
| Rate for Payer: Kentucky WC Medicaid |
$17.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.87
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
NEURON SPECIFIC ENOLASE, S
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
30001824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.87
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
NEURONTIN 250MG/5ML EQU ORSOL
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 42192060816
|
| Hospital Charge Code |
25001067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
NEURONTIN 250MG/5ML EQU ORSOL
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 42192060816
|
| Hospital Charge Code |
25001067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
NEURONTIN (GABAPENT 100MG/1CAP
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 60687058001
|
| Hospital Charge Code |
25001063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| 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 |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| 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 |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
NEURONTIN (GABAPENT 100MG/1CAP
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 60687058001
|
| Hospital Charge Code |
25001063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| 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 |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| 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 |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
NEURONTIN (GABAPENT 300MG/1CAP
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
25001064
|
|
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
|
|
|
NEURONTIN (GABAPENT 300MG/1CAP
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
25001064
|
|
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
|
|
|
NEURONTIN GABAPENTIN 400MG CAP
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 60687060201
|
| Hospital Charge Code |
25001068
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
NEURONTIN GABAPENTIN 400MG CAP
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 60687060201
|
| Hospital Charge Code |
25001068
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
NEURONTIN (GABAPENTIN)600 MG T
|
Facility
|
IP
|
$4.85
|
|
|
Service Code
|
NDC 60687050701
|
| Hospital Charge Code |
25001066
|
|
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
|
|
|
NEURONTIN (GABAPENTIN)600 MG T
|
Facility
|
OP
|
$4.85
|
|
|
Service Code
|
NDC 60687050701
|
| Hospital Charge Code |
25001066
|
|
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: 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
|
| Rate for Payer: Aetna Commercial |
$3.73
|
|
|
NEURONTIN (GABAPENTIN) 800MG T
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687051801
|
| Hospital Charge Code |
25001065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.26
|
| Rate for Payer: First Health Commercial |
$4.87
|
| Rate for Payer: Humana Commercial |
$4.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.51
|
| Rate for Payer: Ohio Health Group HMO |
$3.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.59
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
NEURONTIN (GABAPENTIN) 800MG T
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 60687051801
|
| Hospital Charge Code |
25001065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| Rate for Payer: Anthem Medicaid |
$1.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.26
|
| Rate for Payer: First Health Commercial |
$4.87
|
| Rate for Payer: Humana Commercial |
$4.36
|
| Rate for Payer: Humana KY Medicaid |
$1.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.51
|
| Rate for Payer: Ohio Health Group HMO |
$3.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.59
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
