|
STAGE ONE CEMENT SPACER MOLD
|
Facility
|
IP
|
$12,746.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,657.01 |
| Max. Negotiated Rate |
$12,236.35 |
| Rate for Payer: Aetna Commercial |
$9,814.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,942.04
|
| Rate for Payer: Cash Price |
$6,373.10
|
| Rate for Payer: Cigna Commercial |
$10,579.35
|
| Rate for Payer: First Health Commercial |
$12,108.89
|
| Rate for Payer: Humana Commercial |
$10,834.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,451.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,406.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,823.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,216.66
|
| Rate for Payer: Ohio Health Group HMO |
$9,559.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,549.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,657.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,951.32
|
| Rate for Payer: PHCS Commercial |
$12,236.35
|
| Rate for Payer: United Healthcare All Payer |
$11,216.66
|
|
|
STALEVO - 100 TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781563701
|
| Hospital Charge Code |
25001425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO - 100 TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781563701
|
| Hospital Charge Code |
25001425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO 125 TABLET
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781564101
|
| Hospital Charge Code |
25001427
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO 125 TABLET
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781564101
|
| Hospital Charge Code |
25001427
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO-150 TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781565401
|
| Hospital Charge Code |
25001429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO-150 TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781565401
|
| Hospital Charge Code |
25001429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO 200 TABLET
|
Facility
|
OP
|
$11.09
|
|
|
Service Code
|
NDC 47335000688
|
| Hospital Charge Code |
25001428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$10.65 |
| Rate for Payer: Aetna Commercial |
$8.54
|
| Rate for Payer: Anthem Medicaid |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.65
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: First Health Commercial |
$10.54
|
| Rate for Payer: Humana Commercial |
$9.43
|
| Rate for Payer: Humana KY Medicaid |
$3.81
|
| Rate for Payer: Kentucky WC Medicaid |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.76
|
| Rate for Payer: Ohio Health Group HMO |
$8.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$10.65
|
| Rate for Payer: United Healthcare All Payer |
$9.76
|
|
|
STALEVO 200 TABLET
|
Facility
|
IP
|
$11.09
|
|
|
Service Code
|
NDC 47335000688
|
| Hospital Charge Code |
25001428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$10.65 |
| Rate for Payer: Aetna Commercial |
$8.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.65
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: First Health Commercial |
$10.54
|
| Rate for Payer: Humana Commercial |
$9.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.76
|
| Rate for Payer: Ohio Health Group HMO |
$8.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$10.65
|
| Rate for Payer: United Healthcare All Payer |
$9.76
|
|
|
STALEVO - 50 TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781561301
|
| Hospital Charge Code |
25001426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO - 50 TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781561301
|
| Hospital Charge Code |
25001426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STANDARD OFFSET NEU MOD NECK
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem Medicaid |
$1,358.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Humana KY Medicaid |
$1,358.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,372.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
STANDARD OFFSET NEU MOD NECK
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
STAPH EPI HSP60 GENE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001299
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$23.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$23.39
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$23.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
STAPH EPI HSP60 GENE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001299
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
STAPH LUGDUNENSIS SODA GENE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001304
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
STAPH LUGDUNENSIS SODA GENE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001304
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$23.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$23.39
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$23.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
STAPH SP TUF GENE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001294
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$23.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$23.39
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$23.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
STAPH SP TUF GENE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001294
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
STAR CLOSE SE
|
Facility
|
OP
|
$1,948.50
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
27000043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$253.30 |
| Max. Negotiated Rate |
$1,870.56 |
| Rate for Payer: Aetna Commercial |
$1,500.34
|
| Rate for Payer: Anthem Medicaid |
$670.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.83
|
| Rate for Payer: Cash Price |
$974.25
|
| Rate for Payer: Cigna Commercial |
$1,617.26
|
| Rate for Payer: First Health Commercial |
$1,851.08
|
| Rate for Payer: Humana Commercial |
$1,656.22
|
| Rate for Payer: Humana KY Medicaid |
$670.09
|
| Rate for Payer: Kentucky WC Medicaid |
$676.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$683.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$604.04
|
| Rate for Payer: PHCS Commercial |
$1,870.56
|
| Rate for Payer: United Healthcare All Payer |
$1,714.68
|
|
|
STAR CLOSE SE
|
Facility
|
IP
|
$1,948.50
|
|
|
Service Code
|
HCPCS C1760
|
| Hospital Charge Code |
27000043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$253.30 |
| Max. Negotiated Rate |
$1,870.56 |
| Rate for Payer: Aetna Commercial |
$1,500.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.83
|
| Rate for Payer: Cash Price |
$974.25
|
| Rate for Payer: Cigna Commercial |
$1,617.26
|
| Rate for Payer: First Health Commercial |
$1,851.08
|
| Rate for Payer: Humana Commercial |
$1,656.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$604.04
|
| Rate for Payer: PHCS Commercial |
$1,870.56
|
| Rate for Payer: United Healthcare All Payer |
$1,714.68
|
|
|
STARLIX (NATEGLINIDE)120 MG T
|
Facility
|
OP
|
$10.89
|
|
|
Service Code
|
NDC 60687068421
|
| Hospital Charge Code |
25001430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Aetna Commercial |
$8.39
|
| Rate for Payer: Anthem Medicaid |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.04
|
| Rate for Payer: First Health Commercial |
$10.35
|
| Rate for Payer: Humana Commercial |
$9.26
|
| Rate for Payer: Humana KY Medicaid |
$3.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.58
|
| Rate for Payer: Ohio Health Group HMO |
$8.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$10.45
|
| Rate for Payer: United Healthcare All Payer |
$9.58
|
|
|
STARLIX (NATEGLINIDE)120 MG T
|
Facility
|
IP
|
$10.89
|
|
|
Service Code
|
NDC 60687068421
|
| Hospital Charge Code |
25001430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Aetna Commercial |
$8.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.04
|
| Rate for Payer: First Health Commercial |
$10.35
|
| Rate for Payer: Humana Commercial |
$9.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.58
|
| Rate for Payer: Ohio Health Group HMO |
$8.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$10.45
|
| Rate for Payer: United Healthcare All Payer |
$9.58
|
|
|
STARLIX NATEGLINIDE 60MG TAB
|
Facility
|
IP
|
$10.20
|
|
|
Service Code
|
NDC 60687067321
|
| Hospital Charge Code |
25001431
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.47
|
| Rate for Payer: First Health Commercial |
$9.69
|
| Rate for Payer: Humana Commercial |
$8.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.98
|
| Rate for Payer: Ohio Health Group HMO |
$7.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.79
|
| Rate for Payer: United Healthcare All Payer |
$8.98
|
|
|
STARLIX NATEGLINIDE 60MG TAB
|
Facility
|
OP
|
$10.20
|
|
|
Service Code
|
NDC 60687067321
|
| Hospital Charge Code |
25001431
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem Medicaid |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.47
|
| Rate for Payer: First Health Commercial |
$9.69
|
| Rate for Payer: Humana Commercial |
$8.67
|
| Rate for Payer: Humana KY Medicaid |
$3.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.98
|
| Rate for Payer: Ohio Health Group HMO |
$7.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.79
|
| Rate for Payer: United Healthcare All Payer |
$8.98
|
|
