|
NEOFORM 6*20
|
Facility
|
IP
|
$17,313.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,193.90 |
| Max. Negotiated Rate |
$16,620.48 |
| Rate for Payer: Aetna Commercial |
$13,331.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,504.14
|
| Rate for Payer: Cash Price |
$8,656.50
|
| Rate for Payer: Cigna Commercial |
$14,369.79
|
| Rate for Payer: First Health Commercial |
$16,447.35
|
| Rate for Payer: Humana Commercial |
$14,716.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,196.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,776.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,193.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,235.44
|
| Rate for Payer: Ohio Health Group HMO |
$12,984.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,850.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,062.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,945.97
|
| Rate for Payer: PHCS Commercial |
$16,620.48
|
| Rate for Payer: United Healthcare All Payer |
$15,235.44
|
|
|
NEOFORM 6*20
|
Facility
|
OP
|
$17,313.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,193.90 |
| Max. Negotiated Rate |
$16,620.48 |
| Rate for Payer: Aetna Commercial |
$13,331.01
|
| Rate for Payer: Anthem Medicaid |
$5,953.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,504.14
|
| Rate for Payer: Cash Price |
$8,656.50
|
| Rate for Payer: Cigna Commercial |
$14,369.79
|
| Rate for Payer: First Health Commercial |
$16,447.35
|
| Rate for Payer: Humana Commercial |
$14,716.05
|
| Rate for Payer: Humana KY Medicaid |
$5,953.94
|
| Rate for Payer: Kentucky WC Medicaid |
$6,014.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,196.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,776.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,193.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,073.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,235.44
|
| Rate for Payer: Ohio Health Group HMO |
$12,984.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,850.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,062.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,945.97
|
| Rate for Payer: PHCS Commercial |
$16,620.48
|
| Rate for Payer: United Healthcare All Payer |
$15,235.44
|
|
|
NEOMYCIN SULFATE 50 500MG/1TAB
|
Facility
|
IP
|
$9.11
|
|
|
Service Code
|
NDC 93117701
|
| Hospital Charge Code |
25001057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| 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 |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
NEOMYCIN SULFATE 50 500MG/1TAB
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 93117701
|
| Hospital Charge Code |
25001057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
NEONATE CRIT CARE INITIAL
|
Facility
|
IP
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
51000124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$862.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$873.60
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$929.60
|
| Rate for Payer: First Health Commercial |
$1,064.00
|
| Rate for Payer: Humana Commercial |
$952.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$918.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$826.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$985.60
|
| Rate for Payer: Ohio Health Group HMO |
$840.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$896.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$974.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.80
|
| Rate for Payer: PHCS Commercial |
$1,075.20
|
| Rate for Payer: United Healthcare All Payer |
$985.60
|
|
|
NEONATE CRIT CARE INITIAL
|
Facility
|
OP
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
51000124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$862.40
|
| Rate for Payer: Anthem Medicaid |
$385.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$873.60
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$929.60
|
| Rate for Payer: First Health Commercial |
$1,064.00
|
| Rate for Payer: Humana Commercial |
$952.00
|
| Rate for Payer: Humana KY Medicaid |
$385.17
|
| Rate for Payer: Kentucky WC Medicaid |
$389.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$918.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$826.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$392.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$985.60
|
| Rate for Payer: Ohio Health Group HMO |
$840.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$896.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$974.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.80
|
| Rate for Payer: PHCS Commercial |
$1,075.20
|
| Rate for Payer: United Healthcare All Payer |
$985.60
|
|
|
NEONATE CRIT CARE INITIAL
|
Professional
|
Both
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
51000124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$392.00 |
| Max. Negotiated Rate |
$1,404.86 |
| Rate for Payer: Aetna Commercial |
$1,390.23
|
| Rate for Payer: Ambetter Exchange |
$835.18
|
| Rate for Payer: Anthem Medicaid |
$707.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$835.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$835.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,002.22
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$1,404.86
|
| Rate for Payer: Healthspan PPO |
$1,033.46
|
| Rate for Payer: Humana Medicaid |
$707.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,235.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$835.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$835.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$721.48
|
| Rate for Payer: Molina Healthcare Passport |
$707.33
|
| Rate for Payer: Multiplan PHCS |
$672.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,085.73
|
| Rate for Payer: UHCCP Medicaid |
$392.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$714.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$835.18
|
|
|
NEONATE CRIT CARE INITIAL(P
|
Professional
|
Both
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
510P0124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$392.00 |
| Max. Negotiated Rate |
$1,404.86 |
| Rate for Payer: Aetna Commercial |
$1,390.23
|
| Rate for Payer: Ambetter Exchange |
$835.18
|
| Rate for Payer: Anthem Medicaid |
$707.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$835.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$835.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,002.22
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$1,404.86
|
| Rate for Payer: Healthspan PPO |
$1,033.46
|
| Rate for Payer: Humana Medicaid |
$707.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,235.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$835.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$835.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$721.48
|
| Rate for Payer: Molina Healthcare Passport |
$707.33
|
| Rate for Payer: Multiplan PHCS |
$672.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,085.73
|
| Rate for Payer: UHCCP Medicaid |
$392.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$714.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$835.18
|
|
|
NEONATE CRIT CARE SUBSQ
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
NEONATE CRIT CARE SUBSQ
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
NEONATE CRIT CARE SUBSQ
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$611.72 |
| Rate for Payer: Aetna Commercial |
$602.36
|
| Rate for Payer: Ambetter Exchange |
$361.36
|
| Rate for Payer: Anthem Medicaid |
$308.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$361.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$361.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$433.63
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$611.72
|
| Rate for Payer: Healthspan PPO |
$447.77
|
| Rate for Payer: Humana Medicaid |
$308.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$535.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$361.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$361.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$314.74
|
| Rate for Payer: Molina Healthcare Passport |
$308.57
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$469.77
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$311.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$361.36
|
|
|
NEONATE CRIT CARE SUBSQ(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
510P0125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$611.72 |
| Rate for Payer: Aetna Commercial |
$602.36
|
| Rate for Payer: Ambetter Exchange |
$361.36
|
| Rate for Payer: Anthem Medicaid |
$308.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$361.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$361.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$433.63
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$611.72
|
| Rate for Payer: Healthspan PPO |
$447.77
|
| Rate for Payer: Humana Medicaid |
$308.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$535.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$361.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$361.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$314.74
|
| Rate for Payer: Molina Healthcare Passport |
$308.57
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$469.77
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$311.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$361.36
|
|
|
NEOPOGEN 1 MCG (480 MGS/1.6ML)
|
Facility
|
OP
|
$2,732.25
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
25002060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2,622.96 |
| Rate for Payer: Aetna Commercial |
$2,103.83
|
| Rate for Payer: Anthem Medicaid |
$939.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,131.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.34
|
| Rate for Payer: Cash Price |
$1,366.12
|
| Rate for Payer: Cash Price |
$1,366.12
|
| Rate for Payer: Cigna Commercial |
$2,267.77
|
| Rate for Payer: First Health Commercial |
$2,595.64
|
| Rate for Payer: Humana Commercial |
$2,322.41
|
| Rate for Payer: Humana KY Medicaid |
$939.62
|
| Rate for Payer: Humana Medicare Advantage |
$0.99
|
| Rate for Payer: Kentucky WC Medicaid |
$949.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,240.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,016.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$958.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,404.38
|
| Rate for Payer: Ohio Health Group HMO |
$2,049.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,185.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,377.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,885.25
|
| Rate for Payer: PHCS Commercial |
$2,622.96
|
| Rate for Payer: United Healthcare All Payer |
$2,404.38
|
|
|
NEOPOGEN 1 MCG (480 MGS/1.6ML)
|
Facility
|
IP
|
$2,732.25
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
25002060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$819.67 |
| Max. Negotiated Rate |
$2,622.96 |
| Rate for Payer: Aetna Commercial |
$2,103.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,131.16
|
| Rate for Payer: Cash Price |
$1,366.12
|
| Rate for Payer: Cigna Commercial |
$2,267.77
|
| Rate for Payer: First Health Commercial |
$2,595.64
|
| Rate for Payer: Humana Commercial |
$2,322.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,240.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,016.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$819.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,404.38
|
| Rate for Payer: Ohio Health Group HMO |
$2,049.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,185.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,377.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,885.25
|
| Rate for Payer: PHCS Commercial |
$2,622.96
|
| Rate for Payer: United Healthcare All Payer |
$2,404.38
|
|
|
NEORAL 100MG/ML OR SOL (50ML)
|
Facility
|
IP
|
$29.82
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002493
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$28.63 |
| Rate for Payer: Aetna Commercial |
$22.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.26
|
| Rate for Payer: Cash Price |
$14.91
|
| Rate for Payer: Cigna Commercial |
$24.75
|
| Rate for Payer: First Health Commercial |
$28.33
|
| Rate for Payer: Humana Commercial |
$25.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.24
|
| Rate for Payer: Ohio Health Group HMO |
$22.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.58
|
| Rate for Payer: PHCS Commercial |
$28.63
|
| Rate for Payer: United Healthcare All Payer |
$26.24
|
|
|
NEORAL 100MG/ML OR SOL (50ML)
|
Facility
|
OP
|
$29.82
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002493
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$28.63 |
| Rate for Payer: Aetna Commercial |
$22.96
|
| Rate for Payer: Anthem Medicaid |
$10.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.26
|
| Rate for Payer: Cash Price |
$14.91
|
| Rate for Payer: Cigna Commercial |
$24.75
|
| Rate for Payer: First Health Commercial |
$28.33
|
| Rate for Payer: Humana Commercial |
$25.35
|
| Rate for Payer: Humana KY Medicaid |
$10.26
|
| Rate for Payer: Kentucky WC Medicaid |
$10.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.24
|
| Rate for Payer: Ohio Health Group HMO |
$22.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.58
|
| Rate for Payer: PHCS Commercial |
$28.63
|
| Rate for Payer: United Healthcare All Payer |
$26.24
|
|
|
NEORAL(CYCLOSPORIN 100MG/CAP)
|
Facility
|
IP
|
$28.76
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$27.61 |
| Rate for Payer: Aetna Commercial |
$22.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.43
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cigna Commercial |
$23.87
|
| Rate for Payer: First Health Commercial |
$27.32
|
| Rate for Payer: Humana Commercial |
$24.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.31
|
| Rate for Payer: Ohio Health Group HMO |
$21.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
| Rate for Payer: PHCS Commercial |
$27.61
|
| Rate for Payer: United Healthcare All Payer |
$25.31
|
|
|
NEORAL(CYCLOSPORIN 100MG/CAP)
|
Facility
|
OP
|
$28.76
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$27.61 |
| Rate for Payer: Aetna Commercial |
$22.15
|
| Rate for Payer: Anthem Medicaid |
$9.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.43
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cigna Commercial |
$23.87
|
| Rate for Payer: First Health Commercial |
$27.32
|
| Rate for Payer: Humana Commercial |
$24.45
|
| Rate for Payer: Humana KY Medicaid |
$9.89
|
| Rate for Payer: Kentucky WC Medicaid |
$9.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.31
|
| Rate for Payer: Ohio Health Group HMO |
$21.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
| Rate for Payer: PHCS Commercial |
$27.61
|
| Rate for Payer: United Healthcare All Payer |
$25.31
|
|
|
NEORAL (CYCLOSPORINE 25MG/1CAP
|
Facility
|
IP
|
$9.10
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
25002503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| 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 |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.28
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
|
NEORAL (CYCLOSPORINE 25MG/1CAP
|
Facility
|
OP
|
$9.10
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
25002503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| 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: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| 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: Molina Healthcare Medicaid |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.28
|
| 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 |
$0.43 |
| 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 |
$1.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.99
|
| 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 |
$0.43 |
| 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 |
$1.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.99
|
| 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 |
$35.38 |
| 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 |
$94.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.37
|
| 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 |
$35.38 |
| 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 |
$94.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.37
|
| Rate for Payer: PHCS Commercial |
$113.21
|
| Rate for Payer: United Healthcare All Payer |
$103.78
|
|
|
NEO-SYNEPHRINE 0.5% NASAL SPRY
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 225080547
|
| Hospital Charge Code |
25003731
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
