|
STRAPPING THORAX
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS 29200
|
| Hospital Charge Code |
42000063
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$25.74 |
| Max. Negotiated Rate |
$190.08 |
| Rate for Payer: Aetna Commercial |
$152.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.44
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$164.34
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: Humana Commercial |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$162.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$174.24
|
| Rate for Payer: Ohio Health Group HMO |
$148.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.38
|
| Rate for Payer: PHCS Commercial |
$190.08
|
| Rate for Payer: United Healthcare All Payer |
$174.24
|
|
|
STRAPPING THORAX
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS 29200
|
| Hospital Charge Code |
45000192
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
STRAPPING TOES
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 29550
|
| Hospital Charge Code |
45000204
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.18
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.11
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
STRAPPING TOES
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 29550
|
| Hospital Charge Code |
45000204
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem Medicaid |
$27.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| Rate for Payer: Humana KY Medicaid |
$27.86
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$28.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.11
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
STRAPPING TOES
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 29550
|
| Hospital Charge Code |
76101069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
|
STRAPPING TOES
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 29550
|
| Hospital Charge Code |
76101069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$27.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
|
STRATTERA 100MG EQUIV CAPSULE
|
Facility
|
OP
|
$9.91
|
|
|
Service Code
|
NDC 64980037903
|
| Hospital Charge Code |
25003496
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$7.63
|
| Rate for Payer: Anthem Medicaid |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.73
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna Commercial |
$8.23
|
| Rate for Payer: First Health Commercial |
$9.41
|
| Rate for Payer: Humana Commercial |
$8.42
|
| Rate for Payer: Humana KY Medicaid |
$3.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.72
|
| Rate for Payer: Ohio Health Group HMO |
$7.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$9.51
|
| Rate for Payer: United Healthcare All Payer |
$8.72
|
|
|
STRATTERA 100MG EQUIV CAPSULE
|
Facility
|
IP
|
$9.91
|
|
|
Service Code
|
NDC 64980037903
|
| Hospital Charge Code |
25003496
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$7.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.73
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna Commercial |
$8.23
|
| Rate for Payer: First Health Commercial |
$9.41
|
| Rate for Payer: Humana Commercial |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.72
|
| Rate for Payer: Ohio Health Group HMO |
$7.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$9.51
|
| Rate for Payer: United Healthcare All Payer |
$8.72
|
|
|
STRATTERA 10MG CAPSULE
|
Facility
|
OP
|
$30.18
|
|
|
Service Code
|
NDC 2322730
|
| Hospital Charge Code |
25001436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna Commercial |
$23.24
|
| Rate for Payer: Anthem Medicaid |
$10.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.54
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cigna Commercial |
$25.05
|
| Rate for Payer: First Health Commercial |
$28.67
|
| Rate for Payer: Humana Commercial |
$25.65
|
| Rate for Payer: Humana KY Medicaid |
$10.38
|
| Rate for Payer: Kentucky WC Medicaid |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.56
|
| Rate for Payer: Ohio Health Group HMO |
$22.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.36
|
| Rate for Payer: PHCS Commercial |
$28.97
|
| Rate for Payer: United Healthcare All Payer |
$26.56
|
|
|
STRATTERA 10MG CAPSULE
|
Facility
|
IP
|
$30.18
|
|
|
Service Code
|
NDC 2322730
|
| Hospital Charge Code |
25001436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna Commercial |
$23.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.54
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cigna Commercial |
$25.05
|
| Rate for Payer: First Health Commercial |
$28.67
|
| Rate for Payer: Humana Commercial |
$25.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.56
|
| Rate for Payer: Ohio Health Group HMO |
$22.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.36
|
| Rate for Payer: PHCS Commercial |
$28.97
|
| Rate for Payer: United Healthcare All Payer |
$26.56
|
|
|
STRATTERA 18MG EQUIV CAPSULE
|
Facility
|
OP
|
$9.63
|
|
|
Service Code
|
NDC 64980037403
|
| Hospital Charge Code |
25003497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Anthem Medicaid |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$7.99
|
| Rate for Payer: First Health Commercial |
$9.15
|
| Rate for Payer: Humana Commercial |
$8.19
|
| Rate for Payer: Humana KY Medicaid |
$3.31
|
| Rate for Payer: Kentucky WC Medicaid |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
STRATTERA 18MG EQUIV CAPSULE
|
Facility
|
IP
|
$9.63
|
|
|
Service Code
|
NDC 64980037403
|
| Hospital Charge Code |
25003497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$7.99
|
| Rate for Payer: First Health Commercial |
$9.15
|
| Rate for Payer: Humana Commercial |
$8.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
STRATTERA 80MG EQUIV CAPSULE
|
Facility
|
IP
|
$9.91
|
|
|
Service Code
|
NDC 64980037803
|
| Hospital Charge Code |
25003498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$7.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.73
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna Commercial |
$8.23
|
| Rate for Payer: First Health Commercial |
$9.41
|
| Rate for Payer: Humana Commercial |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.72
|
| Rate for Payer: Ohio Health Group HMO |
$7.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$9.51
|
| Rate for Payer: United Healthcare All Payer |
$8.72
|
|
|
STRATTERA 80MG EQUIV CAPSULE
|
Facility
|
OP
|
$9.91
|
|
|
Service Code
|
NDC 64980037803
|
| Hospital Charge Code |
25003498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$7.63
|
| Rate for Payer: Anthem Medicaid |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.73
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna Commercial |
$8.23
|
| Rate for Payer: First Health Commercial |
$9.41
|
| Rate for Payer: Humana Commercial |
$8.42
|
| Rate for Payer: Humana KY Medicaid |
$3.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.72
|
| Rate for Payer: Ohio Health Group HMO |
$7.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$9.51
|
| Rate for Payer: United Healthcare All Payer |
$8.72
|
|
|
STRATTERA(ATOMOXETINE)25MG CAP
|
Facility
|
OP
|
$30.18
|
|
|
Service Code
|
NDC 2322830
|
| Hospital Charge Code |
25001437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna Commercial |
$23.24
|
| Rate for Payer: Anthem Medicaid |
$10.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.54
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cigna Commercial |
$25.05
|
| Rate for Payer: First Health Commercial |
$28.67
|
| Rate for Payer: Humana Commercial |
$25.65
|
| Rate for Payer: Humana KY Medicaid |
$10.38
|
| Rate for Payer: Kentucky WC Medicaid |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.56
|
| Rate for Payer: Ohio Health Group HMO |
$22.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.36
|
| Rate for Payer: PHCS Commercial |
$28.97
|
| Rate for Payer: United Healthcare All Payer |
$26.56
|
|
|
STRATTERA(ATOMOXETINE)25MG CAP
|
Facility
|
IP
|
$30.18
|
|
|
Service Code
|
NDC 2322830
|
| Hospital Charge Code |
25001437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna Commercial |
$23.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.54
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cigna Commercial |
$25.05
|
| Rate for Payer: First Health Commercial |
$28.67
|
| Rate for Payer: Humana Commercial |
$25.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.56
|
| Rate for Payer: Ohio Health Group HMO |
$22.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.36
|
| Rate for Payer: PHCS Commercial |
$28.97
|
| Rate for Payer: United Healthcare All Payer |
$26.56
|
|
|
STRATTERA(ATOMOXETINE)40MG CAP
|
Facility
|
OP
|
$9.74
|
|
|
Service Code
|
NDC 68462026830
|
| Hospital Charge Code |
25001438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Aetna Commercial |
$7.50
|
| Rate for Payer: Anthem Medicaid |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.60
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Cigna Commercial |
$8.08
|
| Rate for Payer: First Health Commercial |
$9.25
|
| Rate for Payer: Humana Commercial |
$8.28
|
| Rate for Payer: Humana KY Medicaid |
$3.35
|
| Rate for Payer: Kentucky WC Medicaid |
$3.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.57
|
| Rate for Payer: Ohio Health Group HMO |
$7.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$9.35
|
| Rate for Payer: United Healthcare All Payer |
$8.57
|
|
|
STRATTERA(ATOMOXETINE)40MG CAP
|
Facility
|
IP
|
$9.74
|
|
|
Service Code
|
NDC 68462026830
|
| Hospital Charge Code |
25001438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Aetna Commercial |
$7.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.60
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Cigna Commercial |
$8.08
|
| Rate for Payer: First Health Commercial |
$9.25
|
| Rate for Payer: Humana Commercial |
$8.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.57
|
| Rate for Payer: Ohio Health Group HMO |
$7.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$9.35
|
| Rate for Payer: United Healthcare All Payer |
$8.57
|
|
|
STRATTERA(ATOMOXETINE)60MG CAP
|
Facility
|
IP
|
$31.32
|
|
|
Service Code
|
NDC 2323930
|
| Hospital Charge Code |
25001439
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Aetna Commercial |
$24.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.43
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cigna Commercial |
$26.00
|
| Rate for Payer: First Health Commercial |
$29.75
|
| Rate for Payer: Humana Commercial |
$26.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.56
|
| Rate for Payer: Ohio Health Group HMO |
$23.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.71
|
| Rate for Payer: PHCS Commercial |
$30.07
|
| Rate for Payer: United Healthcare All Payer |
$27.56
|
|
|
STRATTERA(ATOMOXETINE)60MG CAP
|
Facility
|
OP
|
$31.32
|
|
|
Service Code
|
NDC 2323930
|
| Hospital Charge Code |
25001439
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Aetna Commercial |
$24.12
|
| Rate for Payer: Anthem Medicaid |
$10.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.43
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cigna Commercial |
$26.00
|
| Rate for Payer: First Health Commercial |
$29.75
|
| Rate for Payer: Humana Commercial |
$26.62
|
| Rate for Payer: Humana KY Medicaid |
$10.77
|
| Rate for Payer: Kentucky WC Medicaid |
$10.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.56
|
| Rate for Payer: Ohio Health Group HMO |
$23.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.71
|
| Rate for Payer: PHCS Commercial |
$30.07
|
| Rate for Payer: United Healthcare All Payer |
$27.56
|
|
|
STRAVIX 2.0CM X 4.0CM
|
Facility
|
OP
|
$9,388.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,220.47 |
| Max. Negotiated Rate |
$9,012.72 |
| Rate for Payer: Aetna Commercial |
$7,228.95
|
| Rate for Payer: Anthem Medicaid |
$3,228.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,322.84
|
| Rate for Payer: Cash Price |
$4,694.12
|
| Rate for Payer: Cigna Commercial |
$7,792.25
|
| Rate for Payer: First Health Commercial |
$8,918.84
|
| Rate for Payer: Humana Commercial |
$7,980.01
|
| Rate for Payer: Humana KY Medicaid |
$3,228.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,261.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,698.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,928.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,816.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,293.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,261.66
|
| Rate for Payer: Ohio Health Group HMO |
$7,041.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,877.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,910.36
|
| Rate for Payer: PHCS Commercial |
$9,012.72
|
| Rate for Payer: United Healthcare All Payer |
$8,261.66
|
|
|
STRAVIX 2.0CM X 4.0CM
|
Facility
|
IP
|
$9,388.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,220.47 |
| Max. Negotiated Rate |
$9,012.72 |
| Rate for Payer: Aetna Commercial |
$7,228.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,322.84
|
| Rate for Payer: Cash Price |
$4,694.12
|
| Rate for Payer: Cigna Commercial |
$7,792.25
|
| Rate for Payer: First Health Commercial |
$8,918.84
|
| Rate for Payer: Humana Commercial |
$7,980.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,698.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,928.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,816.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,261.66
|
| Rate for Payer: Ohio Health Group HMO |
$7,041.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,877.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,910.36
|
| Rate for Payer: PHCS Commercial |
$9,012.72
|
| Rate for Payer: United Healthcare All Payer |
$8,261.66
|
|
|
STRAVIX PL 2 CM X 2 CM
|
Facility
|
IP
|
$7,973.88
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,036.60 |
| Max. Negotiated Rate |
$7,654.92 |
| Rate for Payer: Aetna Commercial |
$6,139.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,219.63
|
| Rate for Payer: Cash Price |
$3,986.94
|
| Rate for Payer: Cigna Commercial |
$6,618.32
|
| Rate for Payer: First Health Commercial |
$7,575.19
|
| Rate for Payer: Humana Commercial |
$6,777.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,538.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,884.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,017.01
|
| Rate for Payer: Ohio Health Group HMO |
$5,980.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,594.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,036.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,471.90
|
| Rate for Payer: PHCS Commercial |
$7,654.92
|
| Rate for Payer: United Healthcare All Payer |
$7,017.01
|
|
|
STRAVIX PL 2 CM X 2 CM
|
Facility
|
OP
|
$7,973.88
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,036.60 |
| Max. Negotiated Rate |
$7,654.92 |
| Rate for Payer: Aetna Commercial |
$6,139.89
|
| Rate for Payer: Anthem Medicaid |
$2,742.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,219.63
|
| Rate for Payer: Cash Price |
$3,986.94
|
| Rate for Payer: Cigna Commercial |
$6,618.32
|
| Rate for Payer: First Health Commercial |
$7,575.19
|
| Rate for Payer: Humana Commercial |
$6,777.80
|
| Rate for Payer: Humana KY Medicaid |
$2,742.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,770.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,538.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,884.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,797.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,017.01
|
| Rate for Payer: Ohio Health Group HMO |
$5,980.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,594.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,036.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,471.90
|
| Rate for Payer: PHCS Commercial |
$7,654.92
|
| Rate for Payer: United Healthcare All Payer |
$7,017.01
|
|
|
STRAVIX PL 2 CM X 4 CM
|
Facility
|
IP
|
$9,388.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,220.47 |
| Max. Negotiated Rate |
$9,012.72 |
| Rate for Payer: Aetna Commercial |
$7,228.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,322.84
|
| Rate for Payer: Cash Price |
$4,694.12
|
| Rate for Payer: Cigna Commercial |
$7,792.25
|
| Rate for Payer: First Health Commercial |
$8,918.84
|
| Rate for Payer: Humana Commercial |
$7,980.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,698.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,928.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,816.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,261.66
|
| Rate for Payer: Ohio Health Group HMO |
$7,041.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,877.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,910.36
|
| Rate for Payer: PHCS Commercial |
$9,012.72
|
| Rate for Payer: United Healthcare All Payer |
$8,261.66
|
|
