|
NEUROMEND 6MM*5.0CM
|
Facility
|
OP
|
$8,748.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.62 |
| Max. Negotiated Rate |
$8,398.80 |
| Rate for Payer: Aetna Commercial |
$6,736.54
|
| Rate for Payer: Anthem Medicaid |
$3,008.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,824.02
|
| Rate for Payer: Cash Price |
$4,374.38
|
| Rate for Payer: Cigna Commercial |
$7,261.46
|
| Rate for Payer: First Health Commercial |
$8,311.31
|
| Rate for Payer: Humana Commercial |
$7,436.44
|
| Rate for Payer: Humana KY Medicaid |
$3,008.70
|
| Rate for Payer: Kentucky WC Medicaid |
$3,039.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,173.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,456.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,624.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,069.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,698.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,561.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,999.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,611.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,036.64
|
| Rate for Payer: PHCS Commercial |
$8,398.80
|
| Rate for Payer: United Healthcare All Payer |
$7,698.90
|
|
|
NEUROMEND 6MM*5.0CM
|
Facility
|
IP
|
$8,748.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.62 |
| Max. Negotiated Rate |
$8,398.80 |
| Rate for Payer: Aetna Commercial |
$6,736.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,824.02
|
| Rate for Payer: Cash Price |
$4,374.38
|
| Rate for Payer: Cigna Commercial |
$7,261.46
|
| Rate for Payer: First Health Commercial |
$8,311.31
|
| Rate for Payer: Humana Commercial |
$7,436.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,173.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,456.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,624.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,698.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,561.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,999.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,611.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,036.64
|
| Rate for Payer: PHCS Commercial |
$8,398.80
|
| Rate for Payer: United Healthcare All Payer |
$7,698.90
|
|
|
NEUROMUCULAR RE ED 15 MIN 1
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
42000018
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$108.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.98
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$117.03
|
| Rate for Payer: First Health Commercial |
$133.95
|
| Rate for Payer: Humana Commercial |
$119.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.08
|
| Rate for Payer: Ohio Health Group HMO |
$105.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.29
|
| Rate for Payer: PHCS Commercial |
$135.36
|
| Rate for Payer: United Healthcare All Payer |
$124.08
|
|
|
NEUROMUCULAR RE ED 15 MIN 1
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS 97112
|
| Hospital Charge Code |
42000018
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$108.57
|
| Rate for Payer: Anthem Medicaid |
$48.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.98
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$117.03
|
| Rate for Payer: First Health Commercial |
$133.95
|
| Rate for Payer: Humana Commercial |
$119.85
|
| Rate for Payer: Humana KY Medicaid |
$48.49
|
| Rate for Payer: Kentucky WC Medicaid |
$48.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.08
|
| Rate for Payer: Ohio Health Group HMO |
$105.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.29
|
| Rate for Payer: PHCS Commercial |
$135.36
|
| Rate for Payer: United Healthcare All Payer |
$124.08
|
|
|
NEURON SPECIFIC ENOLASE, S
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
30001824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$78.72 |
| Rate for Payer: Aetna Commercial |
$63.14
|
| Rate for Payer: Anthem Medicaid |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.85
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.27
|
| Rate for Payer: Cash Price |
$41.00
|
| Rate for Payer: Cash Price |
$41.00
|
| Rate for Payer: Cigna Commercial |
$68.06
|
| Rate for Payer: First Health Commercial |
$77.90
|
| Rate for Payer: Humana Commercial |
$69.70
|
| 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 |
$67.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.16
|
| Rate for Payer: Ohio Health Group HMO |
$61.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.58
|
| Rate for Payer: PHCS Commercial |
$78.72
|
| Rate for Payer: United Healthcare All Payer |
$72.16
|
|
|
NEURON SPECIFIC ENOLASE, S
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
30001824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.60 |
| Max. Negotiated Rate |
$78.72 |
| Rate for Payer: Aetna Commercial |
$63.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.85
|
| Rate for Payer: Cash Price |
$41.00
|
| Rate for Payer: Cigna Commercial |
$68.06
|
| Rate for Payer: First Health Commercial |
$77.90
|
| Rate for Payer: Humana Commercial |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.16
|
| Rate for Payer: Ohio Health Group HMO |
$61.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.58
|
| Rate for Payer: PHCS Commercial |
$78.72
|
| Rate for Payer: United Healthcare All Payer |
$72.16
|
|
|
NEURONTIN 250MG/5ML EQU ORSOL
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 42192060816
|
| Hospital Charge Code |
25001067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| 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 |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
NEURONTIN 250MG/5ML EQU ORSOL
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 42192060816
|
| Hospital Charge Code |
25001067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| 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 |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| 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 |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
NEURONTIN (GABAPENT 300MG/1CAP
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
25001064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
NEURONTIN (GABAPENT 300MG/1CAP
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
25001064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$1.32 |
| 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 |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| 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 |
$1.32 |
| 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 |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| 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 |
$1.46 |
| 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 |
$3.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| 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 |
$1.46 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| 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 |
$3.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
NEURONTIN (GABAPENTIN) 800MG T
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 60687051801
|
| Hospital Charge Code |
25001065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| 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 |
$4.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.54
|
| 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 |
$1.54 |
| 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 |
$4.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.54
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
NEUROPLASTY
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
76102364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.04 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$640.03
|
| Rate for Payer: Ambetter Exchange |
$415.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$263.04
|
| Rate for Payer: Anthem Medicaid |
$284.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$415.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$415.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.88
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$609.80
|
| Rate for Payer: Healthspan PPO |
$501.51
|
| Rate for Payer: Humana Medicaid |
$284.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$530.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$415.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$415.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.47
|
| Rate for Payer: Molina Healthcare Passport |
$284.77
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$540.45
|
| Rate for Payer: UHCCP Medicaid |
$276.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$415.73
|
|
|
NEUROPLASTY
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
76102364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
NEUROPLASTY
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
76102364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$412.68 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL
|
Facility
|
OP
|
$2,526.05
|
|
|
Service Code
|
CPT 64721
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,804.32 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW
|
Facility
|
OP
|
$2,526.05
|
|
|
Service Code
|
CPT 64718
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,804.32 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST
|
Facility
|
OP
|
$2,526.05
|
|
|
Service Code
|
CPT 64719
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,804.32 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
|
|
NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED
|
Facility
|
OP
|
$2,526.05
|
|
|
Service Code
|
CPT 64708
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,804.32 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
|
