|
SUBUTEX [1 MG] 8MG EQUIV TAB
|
Facility
|
OP
|
$62.55
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
25001894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$60.05 |
| Rate for Payer: Aetna Commercial |
$48.16
|
| Rate for Payer: Anthem Medicaid |
$21.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.79
|
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Cigna Commercial |
$51.92
|
| Rate for Payer: First Health Commercial |
$59.42
|
| Rate for Payer: Humana Commercial |
$53.17
|
| Rate for Payer: Humana KY Medicaid |
$21.51
|
| Rate for Payer: Kentucky WC Medicaid |
$21.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.04
|
| Rate for Payer: Ohio Health Group HMO |
$46.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.39
|
| Rate for Payer: PHCS Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Payer |
$55.04
|
|
|
SUCTION LIPECTOMY HEAD&NECK
|
Facility
|
IP
|
$7,447.92
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
76100228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$968.23 |
| Max. Negotiated Rate |
$7,150.00 |
| Rate for Payer: Aetna Commercial |
$5,734.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,809.38
|
| Rate for Payer: Cash Price |
$3,723.96
|
| Rate for Payer: Cigna Commercial |
$6,181.77
|
| Rate for Payer: First Health Commercial |
$7,075.52
|
| Rate for Payer: Humana Commercial |
$6,330.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,107.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,496.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,554.17
|
| Rate for Payer: Ohio Health Group HMO |
$5,585.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,489.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$968.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,308.86
|
| Rate for Payer: PHCS Commercial |
$7,150.00
|
| Rate for Payer: United Healthcare All Payer |
$6,554.17
|
|
|
SUCTION LIPECTOMY HEAD&NECK
|
Professional
|
Both
|
$7,447.92
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
76100228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$7,447.92 |
| Rate for Payer: Aetna Commercial |
$784.40
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,447.92
|
| Rate for Payer: Cash Price |
$3,723.96
|
| Rate for Payer: Cash Price |
$3,723.96
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$144.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$808.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.75
|
| Rate for Payer: Molina Healthcare Passport |
$144.85
|
| Rate for Payer: Multiplan PHCS |
$4,468.75
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,213.54
|
| Rate for Payer: UHCCP Medicaid |
$2,606.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.30
|
|
|
SUCTION LIPECTOMY HEAD&NECK
|
Facility
|
OP
|
$7,447.92
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
76100228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$968.23 |
| Max. Negotiated Rate |
$7,150.00 |
| Rate for Payer: Aetna Commercial |
$5,734.90
|
| Rate for Payer: Anthem Medicaid |
$2,561.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,809.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,723.96
|
| Rate for Payer: Cash Price |
$3,723.96
|
| Rate for Payer: Cigna Commercial |
$6,181.77
|
| Rate for Payer: First Health Commercial |
$7,075.52
|
| Rate for Payer: Humana Commercial |
$6,330.73
|
| Rate for Payer: Humana KY Medicaid |
$2,561.34
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,587.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,107.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,496.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,612.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,554.17
|
| Rate for Payer: Ohio Health Group HMO |
$5,585.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,489.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$968.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,308.86
|
| Rate for Payer: PHCS Commercial |
$7,150.00
|
| Rate for Payer: United Healthcare All Payer |
$6,554.17
|
|
|
SUCTION LIPECTOMY HEAD&NECK(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
761P0228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$784.40
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$144.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$808.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.75
|
| Rate for Payer: Molina Healthcare Passport |
$144.85
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.30
|
|
|
SUCTION LIPECTOMY HEAD&NECK(T
|
Facility
|
IP
|
$5,947.92
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
761T0228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$773.23 |
| Max. Negotiated Rate |
$5,710.00 |
| Rate for Payer: Aetna Commercial |
$4,579.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,639.38
|
| Rate for Payer: Cash Price |
$2,973.96
|
| Rate for Payer: Cigna Commercial |
$4,936.77
|
| Rate for Payer: First Health Commercial |
$5,650.52
|
| Rate for Payer: Humana Commercial |
$5,055.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,877.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,389.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,784.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,234.17
|
| Rate for Payer: Ohio Health Group HMO |
$4,460.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,189.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$773.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,843.86
|
| Rate for Payer: PHCS Commercial |
$5,710.00
|
| Rate for Payer: United Healthcare All Payer |
$5,234.17
|
|
|
SUCTION LIPECTOMY HEAD&NECK(T
|
Facility
|
OP
|
$5,947.92
|
|
|
Service Code
|
HCPCS 15876
|
| Hospital Charge Code |
761T0228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$773.23 |
| Max. Negotiated Rate |
$5,710.00 |
| Rate for Payer: Aetna Commercial |
$4,579.90
|
| Rate for Payer: Anthem Medicaid |
$2,045.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,639.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,973.96
|
| Rate for Payer: Cash Price |
$2,973.96
|
| Rate for Payer: Cigna Commercial |
$4,936.77
|
| Rate for Payer: First Health Commercial |
$5,650.52
|
| Rate for Payer: Humana Commercial |
$5,055.73
|
| Rate for Payer: Humana KY Medicaid |
$2,045.49
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,066.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,877.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,389.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,086.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,234.17
|
| Rate for Payer: Ohio Health Group HMO |
$4,460.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,189.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$773.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,843.86
|
| Rate for Payer: PHCS Commercial |
$5,710.00
|
| Rate for Payer: United Healthcare All Payer |
$5,234.17
|
|
|
SUCTION LIPECTOMY LWR EXTREM
|
Professional
|
Both
|
$8,692.25
|
|
|
Service Code
|
HCPCS 15879
|
| Hospital Charge Code |
76100230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$8,692.25 |
| Rate for Payer: Aetna Commercial |
$1,400.72
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$8,692.25
|
| Rate for Payer: Cash Price |
$4,346.12
|
| Rate for Payer: Cash Price |
$4,346.12
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$144.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,212.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.75
|
| Rate for Payer: Molina Healthcare Passport |
$144.85
|
| Rate for Payer: Multiplan PHCS |
$5,215.35
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$6,084.58
|
| Rate for Payer: UHCCP Medicaid |
$3,042.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.30
|
|
|
SUCTION LIPECTOMY LWR EXTREM
|
Facility
|
IP
|
$8,692.25
|
|
|
Service Code
|
HCPCS 15879
|
| Hospital Charge Code |
76100230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,129.99 |
| Max. Negotiated Rate |
$8,344.56 |
| Rate for Payer: Aetna Commercial |
$6,693.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,779.96
|
| Rate for Payer: Cash Price |
$4,346.12
|
| Rate for Payer: Cigna Commercial |
$7,214.57
|
| Rate for Payer: First Health Commercial |
$8,257.64
|
| Rate for Payer: Humana Commercial |
$7,388.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,127.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,414.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,607.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,649.18
|
| Rate for Payer: Ohio Health Group HMO |
$6,519.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,738.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,129.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,694.60
|
| Rate for Payer: PHCS Commercial |
$8,344.56
|
| Rate for Payer: United Healthcare All Payer |
$7,649.18
|
|
|
SUCTION LIPECTOMY LWR EXTREM
|
Facility
|
OP
|
$8,692.25
|
|
|
Service Code
|
HCPCS 15879
|
| Hospital Charge Code |
76100230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,129.99 |
| Max. Negotiated Rate |
$8,344.56 |
| Rate for Payer: Aetna Commercial |
$6,693.03
|
| Rate for Payer: Anthem Medicaid |
$2,989.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,779.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$4,346.12
|
| Rate for Payer: Cash Price |
$4,346.12
|
| Rate for Payer: Cigna Commercial |
$7,214.57
|
| Rate for Payer: First Health Commercial |
$8,257.64
|
| Rate for Payer: Humana Commercial |
$7,388.41
|
| Rate for Payer: Humana KY Medicaid |
$2,989.26
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,019.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,127.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,414.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,049.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,649.18
|
| Rate for Payer: Ohio Health Group HMO |
$6,519.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,738.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,129.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,694.60
|
| Rate for Payer: PHCS Commercial |
$8,344.56
|
| Rate for Payer: United Healthcare All Payer |
$7,649.18
|
|
|
SUCTION LIPECTOMY LWR EXTRE(P
|
Professional
|
Both
|
$2,050.00
|
|
|
Service Code
|
HCPCS 15879
|
| Hospital Charge Code |
761P0230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna Commercial |
$1,400.72
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,050.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$144.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,212.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.75
|
| Rate for Payer: Molina Healthcare Passport |
$144.85
|
| Rate for Payer: Multiplan PHCS |
$1,230.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,435.00
|
| Rate for Payer: UHCCP Medicaid |
$717.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.30
|
|
|
SUCTION LIPECTOMY LWR EXTRE(T
|
Facility
|
IP
|
$6,642.25
|
|
|
Service Code
|
HCPCS 15879
|
| Hospital Charge Code |
761T0230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$863.49 |
| Max. Negotiated Rate |
$6,376.56 |
| Rate for Payer: Aetna Commercial |
$5,114.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,180.96
|
| Rate for Payer: Cash Price |
$3,321.12
|
| Rate for Payer: Cigna Commercial |
$5,513.07
|
| Rate for Payer: First Health Commercial |
$6,310.14
|
| Rate for Payer: Humana Commercial |
$5,645.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,446.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,901.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,992.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,845.18
|
| Rate for Payer: Ohio Health Group HMO |
$4,981.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,328.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$863.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,059.10
|
| Rate for Payer: PHCS Commercial |
$6,376.56
|
| Rate for Payer: United Healthcare All Payer |
$5,845.18
|
|
|
SUCTION LIPECTOMY LWR EXTRE(T
|
Facility
|
OP
|
$6,642.25
|
|
|
Service Code
|
HCPCS 15879
|
| Hospital Charge Code |
761T0230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$863.49 |
| Max. Negotiated Rate |
$6,376.56 |
| Rate for Payer: Aetna Commercial |
$5,114.53
|
| Rate for Payer: Anthem Medicaid |
$2,284.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,180.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,321.12
|
| Rate for Payer: Cash Price |
$3,321.12
|
| Rate for Payer: Cigna Commercial |
$5,513.07
|
| Rate for Payer: First Health Commercial |
$6,310.14
|
| Rate for Payer: Humana Commercial |
$5,645.91
|
| Rate for Payer: Humana KY Medicaid |
$2,284.27
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,307.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,446.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,901.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,330.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,845.18
|
| Rate for Payer: Ohio Health Group HMO |
$4,981.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,328.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$863.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,059.10
|
| Rate for Payer: PHCS Commercial |
$6,376.56
|
| Rate for Payer: United Healthcare All Payer |
$5,845.18
|
|
|
SUDAFED EQUIV 30MG TABLET
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 904699061
|
| Hospital Charge Code |
25001444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
SUDAFED EQUIV 30MG TABLET
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 904699061
|
| Hospital Charge Code |
25001444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
SUDAFED PE 10 MG TABLET
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 24385060389
|
| Hospital Charge Code |
25001445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SUDAFED PE 10 MG TABLET
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 24385060389
|
| Hospital Charge Code |
25001445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SUDAFED (PSEUDOEPHED 60MG/1TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904672846
|
| Hospital Charge Code |
25001443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
SUDAFED (PSEUDOEPHED 60MG/1TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 904672846
|
| Hospital Charge Code |
25001443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
SULAR 17MG TABLET (SR)
|
Facility
|
OP
|
$22.77
|
|
|
Service Code
|
NDC 378209701
|
| Hospital Charge Code |
25001446
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$21.86 |
| Rate for Payer: Aetna Commercial |
$17.53
|
| Rate for Payer: Anthem Medicaid |
$7.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$18.90
|
| Rate for Payer: First Health Commercial |
$21.63
|
| Rate for Payer: Humana Commercial |
$19.35
|
| Rate for Payer: Humana KY Medicaid |
$7.83
|
| Rate for Payer: Kentucky WC Medicaid |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.06
|
| Rate for Payer: PHCS Commercial |
$21.86
|
| Rate for Payer: United Healthcare All Payer |
$20.04
|
|
|
SULAR 17MG TABLET (SR)
|
Facility
|
IP
|
$22.77
|
|
|
Service Code
|
NDC 378209701
|
| Hospital Charge Code |
25001446
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$21.86 |
| Rate for Payer: Aetna Commercial |
$17.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$18.90
|
| Rate for Payer: First Health Commercial |
$21.63
|
| Rate for Payer: Humana Commercial |
$19.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.06
|
| Rate for Payer: PHCS Commercial |
$21.86
|
| Rate for Payer: United Healthcare All Payer |
$20.04
|
|
|
SULAR 20MG TAB.SR
|
Facility
|
OP
|
$30.16
|
|
|
Service Code
|
NDC 378222201
|
| Hospital Charge Code |
25001447
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$28.95 |
| Rate for Payer: Aetna Commercial |
$23.22
|
| Rate for Payer: Anthem Medicaid |
$10.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.52
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cigna Commercial |
$25.03
|
| Rate for Payer: First Health Commercial |
$28.65
|
| Rate for Payer: Humana Commercial |
$25.64
|
| Rate for Payer: Humana KY Medicaid |
$10.37
|
| Rate for Payer: Kentucky WC Medicaid |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.54
|
| Rate for Payer: Ohio Health Group HMO |
$22.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.35
|
| Rate for Payer: PHCS Commercial |
$28.95
|
| Rate for Payer: United Healthcare All Payer |
$26.54
|
|
|
SULAR 20MG TAB.SR
|
Facility
|
IP
|
$30.16
|
|
|
Service Code
|
NDC 378222201
|
| Hospital Charge Code |
25001447
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$28.95 |
| Rate for Payer: Aetna Commercial |
$23.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.52
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cigna Commercial |
$25.03
|
| Rate for Payer: First Health Commercial |
$28.65
|
| Rate for Payer: Humana Commercial |
$25.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.54
|
| Rate for Payer: Ohio Health Group HMO |
$22.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.35
|
| Rate for Payer: PHCS Commercial |
$28.95
|
| Rate for Payer: United Healthcare All Payer |
$26.54
|
|
|
SULAR 8.5MG TABLET (SR)
|
Facility
|
IP
|
$22.12
|
|
|
Service Code
|
NDC 66993047202
|
| Hospital Charge Code |
25001448
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$17.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.25
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: Cigna Commercial |
$18.36
|
| Rate for Payer: First Health Commercial |
$21.01
|
| Rate for Payer: Humana Commercial |
$18.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.47
|
| Rate for Payer: Ohio Health Group HMO |
$16.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.86
|
| Rate for Payer: PHCS Commercial |
$21.24
|
| Rate for Payer: United Healthcare All Payer |
$19.47
|
|
|
SULAR 8.5MG TABLET (SR)
|
Facility
|
OP
|
$22.12
|
|
|
Service Code
|
NDC 66993047202
|
| Hospital Charge Code |
25001448
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$17.03
|
| Rate for Payer: Anthem Medicaid |
$7.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.25
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: Cigna Commercial |
$18.36
|
| Rate for Payer: First Health Commercial |
$21.01
|
| Rate for Payer: Humana Commercial |
$18.80
|
| Rate for Payer: Humana KY Medicaid |
$7.61
|
| Rate for Payer: Kentucky WC Medicaid |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.47
|
| Rate for Payer: Ohio Health Group HMO |
$16.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.86
|
| Rate for Payer: PHCS Commercial |
$21.24
|
| Rate for Payer: United Healthcare All Payer |
$19.47
|
|
