|
NEXGEN RH KNE TIB AGMT 10M SZ2
|
Facility
|
IP
|
$21,261.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,378.53 |
| Max. Negotiated Rate |
$20,411.29 |
| Rate for Payer: Aetna Commercial |
$16,371.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,584.17
|
| Rate for Payer: Cash Price |
$10,630.88
|
| Rate for Payer: Cigna Commercial |
$17,647.26
|
| Rate for Payer: First Health Commercial |
$20,198.67
|
| Rate for Payer: Humana Commercial |
$18,072.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,434.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,691.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,378.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,710.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,946.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,009.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,497.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,670.61
|
| Rate for Payer: PHCS Commercial |
$20,411.29
|
| Rate for Payer: United Healthcare All Payer |
$18,710.35
|
|
|
NEXGEN RH KNE TIB AGMT 10M SZ3
|
Facility
|
OP
|
$21,224.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,367.28 |
| Max. Negotiated Rate |
$20,375.29 |
| Rate for Payer: Aetna Commercial |
$16,342.68
|
| Rate for Payer: Anthem Medicaid |
$7,299.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,554.92
|
| Rate for Payer: Cash Price |
$10,612.13
|
| Rate for Payer: Cigna Commercial |
$17,616.14
|
| Rate for Payer: First Health Commercial |
$20,163.05
|
| Rate for Payer: Humana Commercial |
$18,040.62
|
| Rate for Payer: Humana KY Medicaid |
$7,299.02
|
| Rate for Payer: Kentucky WC Medicaid |
$7,373.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,403.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,663.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,445.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,677.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,979.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,465.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,644.74
|
| Rate for Payer: PHCS Commercial |
$20,375.29
|
| Rate for Payer: United Healthcare All Payer |
$18,677.35
|
|
|
NEXGEN RH KNE TIB AGMT 10M SZ3
|
Facility
|
IP
|
$21,224.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,367.28 |
| Max. Negotiated Rate |
$20,375.29 |
| Rate for Payer: Aetna Commercial |
$16,342.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,554.92
|
| Rate for Payer: Cash Price |
$10,612.13
|
| Rate for Payer: Cigna Commercial |
$17,616.14
|
| Rate for Payer: First Health Commercial |
$20,163.05
|
| Rate for Payer: Humana Commercial |
$18,040.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,403.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,663.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,677.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,979.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,465.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,644.74
|
| Rate for Payer: PHCS Commercial |
$20,375.29
|
| Rate for Payer: United Healthcare All Payer |
$18,677.35
|
|
|
NEXGEN RH KNE TIB AGMT 10M SZ4
|
Facility
|
OP
|
$21,261.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,378.53 |
| Max. Negotiated Rate |
$20,411.29 |
| Rate for Payer: Aetna Commercial |
$16,371.56
|
| Rate for Payer: Anthem Medicaid |
$7,311.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,584.17
|
| Rate for Payer: Cash Price |
$10,630.88
|
| Rate for Payer: Cigna Commercial |
$17,647.26
|
| Rate for Payer: First Health Commercial |
$20,198.67
|
| Rate for Payer: Humana Commercial |
$18,072.50
|
| Rate for Payer: Humana KY Medicaid |
$7,311.92
|
| Rate for Payer: Kentucky WC Medicaid |
$7,386.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,434.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,691.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,378.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,458.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,710.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,946.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,009.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,497.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,670.61
|
| Rate for Payer: PHCS Commercial |
$20,411.29
|
| Rate for Payer: United Healthcare All Payer |
$18,710.35
|
|
|
NEXGEN RH KNE TIB AGMT 10M SZ4
|
Facility
|
IP
|
$21,261.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,378.53 |
| Max. Negotiated Rate |
$20,411.29 |
| Rate for Payer: Aetna Commercial |
$16,371.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,584.17
|
| Rate for Payer: Cash Price |
$10,630.88
|
| Rate for Payer: Cigna Commercial |
$17,647.26
|
| Rate for Payer: First Health Commercial |
$20,198.67
|
| Rate for Payer: Humana Commercial |
$18,072.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,434.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,691.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,378.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,710.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,946.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,009.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,497.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,670.61
|
| Rate for Payer: PHCS Commercial |
$20,411.29
|
| Rate for Payer: United Healthcare All Payer |
$18,710.35
|
|
|
NEXGEN RH KNE TIB AGMT 10M SZ6
|
Facility
|
IP
|
$21,261.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,378.53 |
| Max. Negotiated Rate |
$20,411.29 |
| Rate for Payer: Aetna Commercial |
$16,371.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,584.17
|
| Rate for Payer: Cash Price |
$10,630.88
|
| Rate for Payer: Cigna Commercial |
$17,647.26
|
| Rate for Payer: First Health Commercial |
$20,198.67
|
| Rate for Payer: Humana Commercial |
$18,072.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,434.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,691.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,378.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,710.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,946.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,009.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,497.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,670.61
|
| Rate for Payer: PHCS Commercial |
$20,411.29
|
| Rate for Payer: United Healthcare All Payer |
$18,710.35
|
|
|
NEXGEN RH KNE TIB AGMT 10M SZ6
|
Facility
|
OP
|
$21,261.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,378.53 |
| Max. Negotiated Rate |
$20,411.29 |
| Rate for Payer: Aetna Commercial |
$16,371.56
|
| Rate for Payer: Anthem Medicaid |
$7,311.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,584.17
|
| Rate for Payer: Cash Price |
$10,630.88
|
| Rate for Payer: Cigna Commercial |
$17,647.26
|
| Rate for Payer: First Health Commercial |
$20,198.67
|
| Rate for Payer: Humana Commercial |
$18,072.50
|
| Rate for Payer: Humana KY Medicaid |
$7,311.92
|
| Rate for Payer: Kentucky WC Medicaid |
$7,386.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,434.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,691.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,378.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,458.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,710.35
|
| Rate for Payer: Ohio Health Group HMO |
$15,946.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,009.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,497.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,670.61
|
| Rate for Payer: PHCS Commercial |
$20,411.29
|
| Rate for Payer: United Healthcare All Payer |
$18,710.35
|
|
|
NEXGEN TAPER PLUG
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
NEXGEN TAPER PLUG
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
NEXGEN TRAB MTAL AUG DST C 5MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
NEXGEN TRAB MTAL AUG DST C 5MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
NEXGEN TRAB MTAL AUG DST D 5MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
NEXGEN TRAB MTAL AUG DST D 5MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
NEXIUM 40MG SUSPENSION PACKET
|
Facility
|
OP
|
$26.58
|
|
|
Service Code
|
NDC 186404001
|
| Hospital Charge Code |
25001072
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$25.52 |
| Rate for Payer: Aetna Commercial |
$20.47
|
| Rate for Payer: Anthem Medicaid |
$9.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.73
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cigna Commercial |
$22.06
|
| Rate for Payer: First Health Commercial |
$25.25
|
| Rate for Payer: Humana Commercial |
$22.59
|
| Rate for Payer: Humana KY Medicaid |
$9.14
|
| Rate for Payer: Kentucky WC Medicaid |
$9.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.39
|
| Rate for Payer: Ohio Health Group HMO |
$19.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.34
|
| Rate for Payer: PHCS Commercial |
$25.52
|
| Rate for Payer: United Healthcare All Payer |
$23.39
|
|
|
NEXIUM 40MG SUSPENSION PACKET
|
Facility
|
IP
|
$26.58
|
|
|
Service Code
|
NDC 186404001
|
| Hospital Charge Code |
25001072
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$25.52 |
| Rate for Payer: Aetna Commercial |
$20.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.73
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cigna Commercial |
$22.06
|
| Rate for Payer: First Health Commercial |
$25.25
|
| Rate for Payer: Humana Commercial |
$22.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.39
|
| Rate for Payer: Ohio Health Group HMO |
$19.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.34
|
| Rate for Payer: PHCS Commercial |
$25.52
|
| Rate for Payer: United Healthcare All Payer |
$23.39
|
|
|
NEXIUM(Esomeprazole) 40mg Cap
|
Facility
|
IP
|
$35.28
|
|
|
Service Code
|
NDC 49999030730
|
| Hospital Charge Code |
25001073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$33.87 |
| Rate for Payer: Aetna Commercial |
$27.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.52
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cigna Commercial |
$29.28
|
| Rate for Payer: First Health Commercial |
$33.52
|
| Rate for Payer: Humana Commercial |
$29.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.05
|
| Rate for Payer: Ohio Health Group HMO |
$26.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.34
|
| Rate for Payer: PHCS Commercial |
$33.87
|
| Rate for Payer: United Healthcare All Payer |
$31.05
|
|
|
NEXIUM(Esomeprazole) 40mg Cap
|
Facility
|
OP
|
$35.28
|
|
|
Service Code
|
NDC 49999030730
|
| Hospital Charge Code |
25001073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$33.87 |
| Rate for Payer: Aetna Commercial |
$27.17
|
| Rate for Payer: Anthem Medicaid |
$12.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.52
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cigna Commercial |
$29.28
|
| Rate for Payer: First Health Commercial |
$33.52
|
| Rate for Payer: Humana Commercial |
$29.99
|
| Rate for Payer: Humana KY Medicaid |
$12.13
|
| Rate for Payer: Kentucky WC Medicaid |
$12.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.05
|
| Rate for Payer: Ohio Health Group HMO |
$26.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.34
|
| Rate for Payer: PHCS Commercial |
$33.87
|
| Rate for Payer: United Healthcare All Payer |
$31.05
|
|
|
NEXIUM (ESOMEPRAZOLE) 40MG VL
|
Facility
|
IP
|
$190.50
|
|
|
Service Code
|
NDC 55150018505
|
| Hospital Charge Code |
25001071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$182.88 |
| Rate for Payer: Aetna Commercial |
$146.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.59
|
| Rate for Payer: Cash Price |
$95.25
|
| Rate for Payer: Cigna Commercial |
$158.12
|
| Rate for Payer: First Health Commercial |
$180.97
|
| Rate for Payer: Humana Commercial |
$161.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.64
|
| Rate for Payer: Ohio Health Group HMO |
$142.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.44
|
| Rate for Payer: PHCS Commercial |
$182.88
|
| Rate for Payer: United Healthcare All Payer |
$167.64
|
|
|
NEXIUM (ESOMEPRAZOLE) 40MG VL
|
Facility
|
OP
|
$190.50
|
|
|
Service Code
|
NDC 55150018505
|
| Hospital Charge Code |
25001071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$182.88 |
| Rate for Payer: Aetna Commercial |
$146.69
|
| Rate for Payer: Anthem Medicaid |
$65.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.59
|
| Rate for Payer: Cash Price |
$95.25
|
| Rate for Payer: Cigna Commercial |
$158.12
|
| Rate for Payer: First Health Commercial |
$180.97
|
| Rate for Payer: Humana Commercial |
$161.93
|
| Rate for Payer: Humana KY Medicaid |
$65.51
|
| Rate for Payer: Kentucky WC Medicaid |
$66.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.64
|
| Rate for Payer: Ohio Health Group HMO |
$142.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.44
|
| Rate for Payer: PHCS Commercial |
$182.88
|
| Rate for Payer: United Healthcare All Payer |
$167.64
|
|
|
NEXPLANON 68 MG IMPL
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
63600074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
NEXPLANON 68 MG IMPL
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
63600074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,419.78 |
| Rate for Payer: Aetna Commercial |
$1,409.77
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,419.78
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,225.00
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
|
|
NEXPLANON 68 MG IMPL
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
63600074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.83
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
NEXPLANON 68 MG IMPL
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
636T0074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
NEXPLANON 68 MG IMPL
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
636T0074
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.83
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
NEXPLANON 68 MG IMPL
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
25002486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.83
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
