|
SIM RPR FACE - EENL5.1-7.5 CM
|
Facility
|
IP
|
$649.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
76100128
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.37 |
| Max. Negotiated Rate |
$623.04 |
| Rate for Payer: Aetna Commercial |
$499.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$506.22
|
| Rate for Payer: Cash Price |
$324.50
|
| Rate for Payer: Cigna Commercial |
$538.67
|
| Rate for Payer: First Health Commercial |
$616.55
|
| Rate for Payer: Humana Commercial |
$551.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$532.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$478.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$571.12
|
| Rate for Payer: Ohio Health Group HMO |
$486.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$129.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.19
|
| Rate for Payer: PHCS Commercial |
$623.04
|
| Rate for Payer: United Healthcare All Payer |
$571.12
|
|
|
SIM RPR FACE - EENL5.1-7.5 CM
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
45000049
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$335.04 |
| Rate for Payer: Aetna Commercial |
$268.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.22
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cigna Commercial |
$289.67
|
| Rate for Payer: First Health Commercial |
$331.55
|
| Rate for Payer: Humana Commercial |
$296.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.12
|
| Rate for Payer: Ohio Health Group HMO |
$261.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.19
|
| Rate for Payer: PHCS Commercial |
$335.04
|
| Rate for Payer: United Healthcare All Payer |
$307.12
|
|
|
SIM RPR FACE - EENL5.1-7.5 C(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
761P0128
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.08 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$213.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$54.08
|
| Rate for Payer: Anthem Medicaid |
$105.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$202.06
|
| Rate for Payer: Healthspan PPO |
$227.29
|
| Rate for Payer: Humana Medicaid |
$105.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.17
|
| Rate for Payer: Molina Healthcare Passport |
$105.07
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$56.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.12
|
|
|
SIM RPR FACE - EENL5.1-7.5 C(T
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
761T0128
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$335.04 |
| Rate for Payer: Aetna Commercial |
$268.73
|
| Rate for Payer: Anthem Medicaid |
$120.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cigna Commercial |
$289.67
|
| Rate for Payer: First Health Commercial |
$331.55
|
| Rate for Payer: Humana Commercial |
$296.65
|
| Rate for Payer: Humana KY Medicaid |
$120.02
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$121.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.12
|
| Rate for Payer: Ohio Health Group HMO |
$261.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.19
|
| Rate for Payer: PHCS Commercial |
$335.04
|
| Rate for Payer: United Healthcare All Payer |
$307.12
|
|
|
SIM RPR FACE - EENL5.1-7.5 C(T
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
761T0128
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$335.04 |
| Rate for Payer: Aetna Commercial |
$268.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.22
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cigna Commercial |
$289.67
|
| Rate for Payer: First Health Commercial |
$331.55
|
| Rate for Payer: Humana Commercial |
$296.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.12
|
| Rate for Payer: Ohio Health Group HMO |
$261.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.19
|
| Rate for Payer: PHCS Commercial |
$335.04
|
| Rate for Payer: United Healthcare All Payer |
$307.12
|
|
|
SIM RPR OVER 30.0 CM
|
Facility
|
OP
|
$1,214.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
76100125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.82 |
| Max. Negotiated Rate |
$1,165.44 |
| Rate for Payer: Aetna Commercial |
$934.78
|
| Rate for Payer: Anthem Medicaid |
$417.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$946.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$607.00
|
| Rate for Payer: Cash Price |
$607.00
|
| Rate for Payer: Cigna Commercial |
$1,007.62
|
| Rate for Payer: First Health Commercial |
$1,153.30
|
| Rate for Payer: Humana Commercial |
$1,031.90
|
| Rate for Payer: Humana KY Medicaid |
$417.49
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$421.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$995.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$895.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$425.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,068.32
|
| Rate for Payer: Ohio Health Group HMO |
$910.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.34
|
| Rate for Payer: PHCS Commercial |
$1,165.44
|
| Rate for Payer: United Healthcare All Payer |
$1,068.32
|
|
|
SIM RPR OVER 30.0 CM
|
Professional
|
Both
|
$1,214.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
76100125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.97 |
| Max. Negotiated Rate |
$1,214.00 |
| Rate for Payer: Aetna Commercial |
$355.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$101.97
|
| Rate for Payer: Anthem Medicaid |
$172.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,214.00
|
| Rate for Payer: Cash Price |
$607.00
|
| Rate for Payer: Cash Price |
$607.00
|
| Rate for Payer: Cigna Commercial |
$339.94
|
| Rate for Payer: Healthspan PPO |
$364.76
|
| Rate for Payer: Humana Medicaid |
$172.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$209.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.77
|
| Rate for Payer: Molina Healthcare Passport |
$172.32
|
| Rate for Payer: Multiplan PHCS |
$728.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$849.80
|
| Rate for Payer: UHCCP Medicaid |
$107.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.04
|
|
|
SIM RPR OVER 30.0 CM
|
Facility
|
IP
|
$1,214.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
76100125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.82 |
| Max. Negotiated Rate |
$1,165.44 |
| Rate for Payer: Aetna Commercial |
$934.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$946.92
|
| Rate for Payer: Cash Price |
$607.00
|
| Rate for Payer: Cigna Commercial |
$1,007.62
|
| Rate for Payer: First Health Commercial |
$1,153.30
|
| Rate for Payer: Humana Commercial |
$1,031.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$995.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$895.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$364.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,068.32
|
| Rate for Payer: Ohio Health Group HMO |
$910.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.34
|
| Rate for Payer: PHCS Commercial |
$1,165.44
|
| Rate for Payer: United Healthcare All Payer |
$1,068.32
|
|
|
SIM RPR OVER 30.0 CM(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
761P0125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.97 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$355.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$101.97
|
| Rate for Payer: Anthem Medicaid |
$172.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$339.94
|
| Rate for Payer: Healthspan PPO |
$364.76
|
| Rate for Payer: Humana Medicaid |
$172.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$209.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.77
|
| Rate for Payer: Molina Healthcare Passport |
$172.32
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$107.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.04
|
|
|
SIM RPR OVER 30.0 CM(T
|
Facility
|
IP
|
$764.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
761T0125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.32 |
| Max. Negotiated Rate |
$733.44 |
| Rate for Payer: Aetna Commercial |
$588.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.92
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cigna Commercial |
$634.12
|
| Rate for Payer: First Health Commercial |
$725.80
|
| Rate for Payer: Humana Commercial |
$649.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$626.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$672.32
|
| Rate for Payer: Ohio Health Group HMO |
$573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.84
|
| Rate for Payer: PHCS Commercial |
$733.44
|
| Rate for Payer: United Healthcare All Payer |
$672.32
|
|
|
SIM RPR OVER 30.0 CM(T
|
Facility
|
OP
|
$764.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
761T0125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.32 |
| Max. Negotiated Rate |
$733.44 |
| Rate for Payer: Aetna Commercial |
$588.28
|
| Rate for Payer: Anthem Medicaid |
$262.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cigna Commercial |
$634.12
|
| Rate for Payer: First Health Commercial |
$725.80
|
| Rate for Payer: Humana Commercial |
$649.40
|
| Rate for Payer: Humana KY Medicaid |
$262.74
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$265.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$626.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$268.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$672.32
|
| Rate for Payer: Ohio Health Group HMO |
$573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.84
|
| Rate for Payer: PHCS Commercial |
$733.44
|
| Rate for Payer: United Healthcare All Payer |
$672.32
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$61,552.46
|
|
|
Service Code
|
MSDRG 008
|
| Min. Negotiated Rate |
$41,767.74 |
| Max. Negotiated Rate |
$61,552.46 |
| Rate for Payer: Anthem Medicaid |
$41,767.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$43,966.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61,552.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$59,354.15
|
| Rate for Payer: Humana KY Medicaid |
$41,767.74
|
| Rate for Payer: Humana Medicare Advantage |
$43,966.04
|
| Rate for Payer: Kentucky WC Medicaid |
$42,185.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52,759.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$42,603.09
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$93,509.60
|
|
|
Service Code
|
MSDRG 019
|
| Min. Negotiated Rate |
$63,452.94 |
| Max. Negotiated Rate |
$93,509.60 |
| Rate for Payer: Anthem Medicaid |
$63,452.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$66,792.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$93,509.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$90,169.97
|
| Rate for Payer: Humana KY Medicaid |
$63,452.94
|
| Rate for Payer: Humana Medicare Advantage |
$66,792.57
|
| Rate for Payer: Kentucky WC Medicaid |
$64,087.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80,151.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$64,722.00
|
|
|
SINEMET CR 25/100MG TAB
|
Facility
|
IP
|
$4.98
|
|
|
Service Code
|
NDC 68084028101
|
| Hospital Charge Code |
25001402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.73
|
| Rate for Payer: Humana Commercial |
$4.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
SINEMET CR 25/100MG TAB
|
Facility
|
OP
|
$4.98
|
|
|
Service Code
|
NDC 68084028101
|
| Hospital Charge Code |
25001402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem Medicaid |
$1.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.73
|
| Rate for Payer: Humana Commercial |
$4.23
|
| Rate for Payer: Humana KY Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
SINEMET CR (LEVO/CARB) 50 1TAB
|
Facility
|
IP
|
$4.93
|
|
|
Service Code
|
NDC 68084028201
|
| Hospital Charge Code |
25001401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.09
|
| Rate for Payer: First Health Commercial |
$4.68
|
| Rate for Payer: Humana Commercial |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.34
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
SINEMET CR (LEVO/CARB) 50 1TAB
|
Facility
|
OP
|
$4.93
|
|
|
Service Code
|
NDC 68084028201
|
| Hospital Charge Code |
25001401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.09
|
| Rate for Payer: First Health Commercial |
$4.68
|
| Rate for Payer: Humana Commercial |
$4.19
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.34
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 50228045901
|
| Hospital Charge Code |
25001399
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
25001400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
25001400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
25001398
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
25001398
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 50228045901
|
| Hospital Charge Code |
25001399
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
SINEQUAN (DOXEPIN) 1 10MG/1CAP
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
25001403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.69
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.49
|
| Rate for Payer: Humana Commercial |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.16
|
| Rate for Payer: Ohio Health Group HMO |
$3.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SINEQUAN (DOXEPIN) 1 10MG/1CAP
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
25001403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.69
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.49
|
| Rate for Payer: Humana Commercial |
$4.02
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.16
|
| Rate for Payer: Ohio Health Group HMO |
$3.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
