|
NIX COMP LICE TX KIT COMBO PKG
|
Facility
|
IP
|
$34.94
|
|
|
Service Code
|
NDC 63736024797
|
| Hospital Charge Code |
25001090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.54 |
| Max. Negotiated Rate |
$33.54 |
| Rate for Payer: Aetna Commercial |
$26.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.25
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cigna Commercial |
$29.00
|
| Rate for Payer: First Health Commercial |
$33.19
|
| Rate for Payer: Humana Commercial |
$29.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.75
|
| Rate for Payer: Ohio Health Group HMO |
$26.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.83
|
| Rate for Payer: PHCS Commercial |
$33.54
|
| Rate for Payer: United Healthcare All Payer |
$30.75
|
|
|
NIX (PERMETHRIN) CREME RIN 2OZ
|
Facility
|
OP
|
$25.22
|
|
|
Service Code
|
NDC 46122010846
|
| Hospital Charge Code |
25001089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$19.42
|
| Rate for Payer: Anthem Medicaid |
$8.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.67
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cigna Commercial |
$20.93
|
| Rate for Payer: First Health Commercial |
$23.96
|
| Rate for Payer: Humana Commercial |
$21.44
|
| Rate for Payer: Humana KY Medicaid |
$8.67
|
| Rate for Payer: Kentucky WC Medicaid |
$8.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.19
|
| Rate for Payer: Ohio Health Group HMO |
$18.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.82
|
| Rate for Payer: PHCS Commercial |
$24.21
|
| Rate for Payer: United Healthcare All Payer |
$22.19
|
|
|
NIX (PERMETHRIN) CREME RIN 2OZ
|
Facility
|
IP
|
$25.22
|
|
|
Service Code
|
NDC 46122010846
|
| Hospital Charge Code |
25001089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$19.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.67
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cigna Commercial |
$20.93
|
| Rate for Payer: First Health Commercial |
$23.96
|
| Rate for Payer: Humana Commercial |
$21.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.19
|
| Rate for Payer: Ohio Health Group HMO |
$18.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.82
|
| Rate for Payer: PHCS Commercial |
$24.21
|
| Rate for Payer: United Healthcare All Payer |
$22.19
|
|
|
NIZORAL (KETOCONAZO 200MG/1TAB
|
Facility
|
OP
|
$9.05
|
|
|
Service Code
|
NDC 35573043330
|
| Hospital Charge Code |
25001091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
NIZORAL (KETOCONAZO 200MG/1TAB
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 35573043330
|
| Hospital Charge Code |
25001091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
NIZORAL(KETOCONAZOLE)2% C 30GM
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
NDC 168009930
|
| Hospital Charge Code |
25001092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.56
|
| Rate for Payer: Anthem Medicaid |
$1.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.60
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: First Health Commercial |
$3.16
|
| Rate for Payer: Humana Commercial |
$2.83
|
| Rate for Payer: Humana KY Medicaid |
$1.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.93
|
| Rate for Payer: Ohio Health Group HMO |
$2.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.03
|
| Rate for Payer: PHCS Commercial |
$3.20
|
| Rate for Payer: United Healthcare All Payer |
$2.93
|
|
|
NIZORAL(KETOCONAZOLE)2% C 30GM
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
NDC 168009930
|
| Hospital Charge Code |
25001092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.60
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: First Health Commercial |
$3.16
|
| Rate for Payer: Humana Commercial |
$2.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.93
|
| Rate for Payer: Ohio Health Group HMO |
$2.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.03
|
| Rate for Payer: PHCS Commercial |
$3.20
|
| Rate for Payer: United Healthcare All Payer |
$2.93
|
|
|
NIZORAL(KETOCONAZOLE)2% SH 4OZ
|
Facility
|
OP
|
$9.47
|
|
|
Service Code
|
NDC 63646001004
|
| Hospital Charge Code |
25001093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$7.29
|
| Rate for Payer: Anthem Medicaid |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.39
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.86
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: Humana Commercial |
$8.05
|
| Rate for Payer: Humana KY Medicaid |
$3.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.09
|
| Rate for Payer: United Healthcare All Payer |
$8.33
|
|
|
NIZORAL(KETOCONAZOLE)2% SH 4OZ
|
Facility
|
IP
|
$9.47
|
|
|
Service Code
|
NDC 63646001004
|
| Hospital Charge Code |
25001093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$7.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.39
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.86
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: Humana Commercial |
$8.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.09
|
| Rate for Payer: United Healthcare All Payer |
$8.33
|
|
|
NJX AA&/STRD AX NERVE IMG
|
Facility
|
OP
|
$2,085.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
76102829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem Medicaid |
$717.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Humana KY Medicaid |
$717.03
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$724.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$731.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
NJX AA&/STRD AX NERVE IMG
|
Professional
|
Both
|
$2,085.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
76102829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$2,085.00 |
| Rate for Payer: Aetna Commercial |
$119.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$49.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,085.00
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$113.07
|
| Rate for Payer: Healthspan PPO |
$158.41
|
| Rate for Payer: Humana Medicaid |
$49.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.39
|
| Rate for Payer: Molina Healthcare Passport |
$49.40
|
| Rate for Payer: Multiplan PHCS |
$1,251.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,459.50
|
| Rate for Payer: UHCCP Medicaid |
$32.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.89
|
|
|
NJX AA&/STRD AX NERVE IMG
|
Facility
|
IP
|
$2,085.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
76102829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
NJX AA&/STRD AX NERVE IMG(P
|
Professional
|
Both
|
$180.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
761P2829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$119.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$49.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$180.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$113.07
|
| Rate for Payer: Healthspan PPO |
$158.41
|
| Rate for Payer: Humana Medicaid |
$49.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.39
|
| Rate for Payer: Molina Healthcare Passport |
$49.40
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$126.00
|
| Rate for Payer: UHCCP Medicaid |
$32.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.89
|
|
|
NJX AA&/STRD AX NERVE IMG(T
|
Facility
|
OP
|
$1,905.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
761T2829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.65 |
| Max. Negotiated Rate |
$1,828.80 |
| Rate for Payer: Aetna Commercial |
$1,466.85
|
| Rate for Payer: Anthem Medicaid |
$655.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$952.50
|
| Rate for Payer: Cash Price |
$952.50
|
| Rate for Payer: Cigna Commercial |
$1,581.15
|
| Rate for Payer: First Health Commercial |
$1,809.75
|
| Rate for Payer: Humana Commercial |
$1,619.25
|
| Rate for Payer: Humana KY Medicaid |
$655.13
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$661.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,562.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,676.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.55
|
| Rate for Payer: PHCS Commercial |
$1,828.80
|
| Rate for Payer: United Healthcare All Payer |
$1,676.40
|
|
|
NJX AA&/STRD AX NERVE IMG(T
|
Facility
|
IP
|
$1,905.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
761T2829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.65 |
| Max. Negotiated Rate |
$1,828.80 |
| Rate for Payer: Aetna Commercial |
$1,466.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.90
|
| Rate for Payer: Cash Price |
$952.50
|
| Rate for Payer: Cigna Commercial |
$1,581.15
|
| Rate for Payer: First Health Commercial |
$1,809.75
|
| Rate for Payer: Humana Commercial |
$1,619.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,562.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,676.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.55
|
| Rate for Payer: PHCS Commercial |
$1,828.80
|
| Rate for Payer: United Healthcare All Payer |
$1,676.40
|
|
|
NJX AA&/STRD GNCLR NRV BRNCH
|
Facility
|
IP
|
$2,240.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
76102817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$291.20 |
| Max. Negotiated Rate |
$2,150.40 |
| Rate for Payer: Aetna Commercial |
$1,724.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,747.20
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cigna Commercial |
$1,859.20
|
| Rate for Payer: First Health Commercial |
$2,128.00
|
| Rate for Payer: Humana Commercial |
$1,904.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,836.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,653.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$672.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,971.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$694.40
|
| Rate for Payer: PHCS Commercial |
$2,150.40
|
| Rate for Payer: United Healthcare All Payer |
$1,971.20
|
|
|
NJX AA&/STRD GNCLR NRV BRNCH
|
Professional
|
Both
|
$2,240.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
76102817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.98 |
| Max. Negotiated Rate |
$2,240.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.29
|
| Rate for Payer: Anthem Medicaid |
$65.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,240.00
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Humana Medicaid |
$65.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$106.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.30
|
| Rate for Payer: Molina Healthcare Passport |
$65.98
|
| Rate for Payer: Multiplan PHCS |
$1,344.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,568.00
|
| Rate for Payer: UHCCP Medicaid |
$69.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.64
|
|
|
NJX AA&/STRD GNCLR NRV BRNCH
|
Facility
|
OP
|
$2,240.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
76102817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$291.20 |
| Max. Negotiated Rate |
$2,150.40 |
| Rate for Payer: Aetna Commercial |
$1,724.80
|
| Rate for Payer: Anthem Medicaid |
$770.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,747.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cigna Commercial |
$1,859.20
|
| Rate for Payer: First Health Commercial |
$2,128.00
|
| Rate for Payer: Humana Commercial |
$1,904.00
|
| Rate for Payer: Humana KY Medicaid |
$770.34
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$778.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,836.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,653.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$785.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,971.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$694.40
|
| Rate for Payer: PHCS Commercial |
$2,150.40
|
| Rate for Payer: United Healthcare All Payer |
$1,971.20
|
|
|
NJX AA&/STRD GNCLR NRV BRNCH(P
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
761P2817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.98 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.29
|
| Rate for Payer: Anthem Medicaid |
$65.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.00
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Humana Medicaid |
$65.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$106.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.30
|
| Rate for Payer: Molina Healthcare Passport |
$65.98
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$69.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.64
|
|
|
NJX AA&/STRD GNCLR NRV BRNCH(T
|
Facility
|
OP
|
$1,995.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
761T2817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$259.35 |
| Max. Negotiated Rate |
$1,915.20 |
| Rate for Payer: Aetna Commercial |
$1,536.15
|
| Rate for Payer: Anthem Medicaid |
$686.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,556.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$997.50
|
| Rate for Payer: Cash Price |
$997.50
|
| Rate for Payer: Cigna Commercial |
$1,655.85
|
| Rate for Payer: First Health Commercial |
$1,895.25
|
| Rate for Payer: Humana Commercial |
$1,695.75
|
| Rate for Payer: Humana KY Medicaid |
$686.08
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$693.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,635.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,472.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$699.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,755.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,496.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$259.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$618.45
|
| Rate for Payer: PHCS Commercial |
$1,915.20
|
| Rate for Payer: United Healthcare All Payer |
$1,755.60
|
|
|
NJX AA&/STRD GNCLR NRV BRNCH(T
|
Facility
|
IP
|
$1,995.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
761T2817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$259.35 |
| Max. Negotiated Rate |
$1,915.20 |
| Rate for Payer: Aetna Commercial |
$1,536.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,556.10
|
| Rate for Payer: Cash Price |
$997.50
|
| Rate for Payer: Cigna Commercial |
$1,655.85
|
| Rate for Payer: First Health Commercial |
$1,895.25
|
| Rate for Payer: Humana Commercial |
$1,695.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,635.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,472.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$598.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,755.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,496.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$259.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$618.45
|
| Rate for Payer: PHCS Commercial |
$1,915.20
|
| Rate for Payer: United Healthcare All Payer |
$1,755.60
|
|
|
NJX AA&/STRD NRV NRVTG SI JT
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 64451
|
| Hospital Charge Code |
76102706
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$64.44
|
| Rate for Payer: Anthem Medicaid |
$64.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$420.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Humana Medicaid |
$64.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.44
|
| Rate for Payer: Molina Healthcare Passport |
$64.16
|
| Rate for Payer: Multiplan PHCS |
$252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$294.00
|
| Rate for Payer: UHCCP Medicaid |
$67.66
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.80
|
|
|
NJX AA&/STRD NRV NRVTG SI JT
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
HCPCS 64451
|
| Hospital Charge Code |
76102706
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.60
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
NJX AA&/STRD NRV NRVTG SI JT
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
HCPCS 64451
|
| Hospital Charge Code |
76102706
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem Medicaid |
$144.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Humana KY Medicaid |
$144.44
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$145.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
NJX ANES STELLTE GANG CRV SYMP
|
Facility
|
OP
|
$2,431.08
|
|
|
Service Code
|
HCPCS 64510
|
| Hospital Charge Code |
76102333
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$316.04 |
| Max. Negotiated Rate |
$2,333.84 |
| Rate for Payer: Aetna Commercial |
$1,871.93
|
| Rate for Payer: Anthem Medicaid |
$836.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,896.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,215.54
|
| Rate for Payer: Cash Price |
$1,215.54
|
| Rate for Payer: Cigna Commercial |
$2,017.80
|
| Rate for Payer: First Health Commercial |
$2,309.53
|
| Rate for Payer: Humana Commercial |
$2,066.42
|
| Rate for Payer: Humana KY Medicaid |
$836.05
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$844.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,993.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,794.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$852.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,139.35
|
| Rate for Payer: Ohio Health Group HMO |
$1,823.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$486.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$753.63
|
| Rate for Payer: PHCS Commercial |
$2,333.84
|
| Rate for Payer: United Healthcare All Payer |
$2,139.35
|
|
