|
SIM RPR FACE - EENL5.1-7.5 C(T
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
761T0128
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$356.16 |
| Rate for Payer: Aetna Commercial |
$285.67
|
| Rate for Payer: Anthem Medicaid |
$127.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$289.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$307.93
|
| Rate for Payer: First Health Commercial |
$352.45
|
| Rate for Payer: Humana Commercial |
$315.35
|
| Rate for Payer: Humana KY Medicaid |
$127.59
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$128.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$304.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$326.48
|
| Rate for Payer: Ohio Health Group HMO |
$278.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$322.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.99
|
| Rate for Payer: PHCS Commercial |
$356.16
|
| Rate for Payer: United Healthcare All Payer |
$326.48
|
|
|
SIM RPR OVER 30.0 CM
|
Facility
|
OP
|
$1,264.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
76100125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$1,213.44 |
| Rate for Payer: Aetna Commercial |
$973.28
|
| Rate for Payer: Anthem Medicaid |
$434.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$985.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Cigna Commercial |
$1,049.12
|
| Rate for Payer: First Health Commercial |
$1,200.80
|
| Rate for Payer: Humana Commercial |
$1,074.40
|
| Rate for Payer: Humana KY Medicaid |
$434.69
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$439.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,036.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$932.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$443.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,112.32
|
| Rate for Payer: Ohio Health Group HMO |
$948.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,011.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,099.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$872.16
|
| Rate for Payer: PHCS Commercial |
$1,213.44
|
| Rate for Payer: United Healthcare All Payer |
$1,112.32
|
|
|
SIM RPR OVER 30.0 CM
|
Professional
|
Both
|
$1,264.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
76100125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.97 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$355.03
|
| Rate for Payer: Ambetter Exchange |
$138.27
|
| 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 Individual/Medicaid |
$138.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.92
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Cash Price |
$632.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$138.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.77
|
| Rate for Payer: Molina Healthcare Passport |
$172.32
|
| Rate for Payer: Multiplan PHCS |
$758.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.75
|
| Rate for Payer: UHCCP Medicaid |
$107.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.04
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.27
|
|
|
SIM RPR OVER 30.0 CM
|
Facility
|
IP
|
$1,264.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
76100125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$379.20 |
| Max. Negotiated Rate |
$1,213.44 |
| Rate for Payer: Aetna Commercial |
$973.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$985.92
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Cigna Commercial |
$1,049.12
|
| Rate for Payer: First Health Commercial |
$1,200.80
|
| Rate for Payer: Humana Commercial |
$1,074.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,036.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$932.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$379.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,112.32
|
| Rate for Payer: Ohio Health Group HMO |
$948.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,011.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,099.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$872.16
|
| Rate for Payer: PHCS Commercial |
$1,213.44
|
| Rate for Payer: United Healthcare All Payer |
$1,112.32
|
|
|
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 |
$364.76 |
| Rate for Payer: Aetna Commercial |
$355.03
|
| Rate for Payer: Ambetter Exchange |
$138.27
|
| 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 Individual/Medicaid |
$138.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.92
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$138.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.27
|
| 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 |
$179.75
|
| Rate for Payer: UHCCP Medicaid |
$107.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.04
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.27
|
|
|
SIM RPR OVER 30.0 CM(T
|
Facility
|
IP
|
$814.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
761T0125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$244.20 |
| Max. Negotiated Rate |
$781.44 |
| Rate for Payer: Aetna Commercial |
$626.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$634.92
|
| Rate for Payer: Cash Price |
$407.00
|
| Rate for Payer: Cigna Commercial |
$675.62
|
| Rate for Payer: First Health Commercial |
$773.30
|
| Rate for Payer: Humana Commercial |
$691.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$667.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$600.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$716.32
|
| Rate for Payer: Ohio Health Group HMO |
$610.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$651.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$708.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.66
|
| Rate for Payer: PHCS Commercial |
$781.44
|
| Rate for Payer: United Healthcare All Payer |
$716.32
|
|
|
SIM RPR OVER 30.0 CM(T
|
Facility
|
OP
|
$814.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
761T0125
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$781.44 |
| Rate for Payer: Aetna Commercial |
$626.78
|
| Rate for Payer: Anthem Medicaid |
$279.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$634.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$407.00
|
| Rate for Payer: Cash Price |
$407.00
|
| Rate for Payer: Cigna Commercial |
$675.62
|
| Rate for Payer: First Health Commercial |
$773.30
|
| Rate for Payer: Humana Commercial |
$691.90
|
| Rate for Payer: Humana KY Medicaid |
$279.93
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$282.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$667.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$600.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$285.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$716.32
|
| Rate for Payer: Ohio Health Group HMO |
$610.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$651.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$708.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.66
|
| Rate for Payer: PHCS Commercial |
$781.44
|
| Rate for Payer: United Healthcare All Payer |
$716.32
|
|
|
SINEMET CR 25/100MG TAB
|
Facility
|
OP
|
$4.98
|
|
|
Service Code
|
NDC 68084028101
|
| Hospital Charge Code |
25001402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
SINEMET CR 25/100MG TAB
|
Facility
|
IP
|
$4.98
|
|
|
Service Code
|
NDC 68084028101
|
| Hospital Charge Code |
25001402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
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 |
$1.48 |
| 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 |
$3.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.40
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
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 |
$1.48 |
| 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 |
$3.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.40
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
25001398
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 50228045901
|
| Hospital Charge Code |
25001399
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| 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 |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 50228045901
|
| Hospital Charge Code |
25001399
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| 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 |
$3.53
|
| 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 |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| 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 |
$1.37 |
| 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 |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
25001400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
SINEMET (LEVO/CARBIDOPA) 1TAB
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
25001400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
SINEQUAN (DOXEPIN) 1 10MG/1CAP
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
25001403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| 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 |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SINEQUAN (DOXEPIN) 1 10MG/1CAP
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
25001403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| 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 |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SINEQUAN (DOXEPIN) 2 25MG/1CAP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 27241016801
|
| Hospital Charge Code |
25001404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
SINEQUAN (DOXEPIN) 2 25MG/1CAP
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 27241016801
|
| Hospital Charge Code |
25001404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
SINGLE CHAMBER PACE MAKER
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
76101242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
SINGLE CHAMBER PACE MAKER
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
76101242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$417.13 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$783.12
|
| Rate for Payer: Ambetter Exchange |
$423.80
|
| Rate for Payer: Anthem Medicaid |
$417.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$423.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$423.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$508.56
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$731.76
|
| Rate for Payer: Healthspan PPO |
$769.96
|
| Rate for Payer: Humana Medicaid |
$417.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$644.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$423.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$423.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$425.47
|
| Rate for Payer: Molina Healthcare Passport |
$417.13
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$550.94
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$421.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$423.80
|
|
|
SINGLE CHAMBER PACE MAKER
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
76101242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.24 |
| Max. Negotiated Rate |
$13,537.66 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,669.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,537.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,054.18
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$9,669.76
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,603.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
SINGLE CHAMBER PACE MAKER(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
761P1242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$417.13 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$783.12
|
| Rate for Payer: Ambetter Exchange |
$423.80
|
| Rate for Payer: Anthem Medicaid |
$417.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$423.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$423.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$508.56
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$731.76
|
| Rate for Payer: Healthspan PPO |
$769.96
|
| Rate for Payer: Humana Medicaid |
$417.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$644.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$423.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$423.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$425.47
|
| Rate for Payer: Molina Healthcare Passport |
$417.13
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$550.94
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$421.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$423.80
|
|
