|
SYN POR PLUS HA SO STEM SZ 14
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 14
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 15
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 15
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 16
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 16
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 17
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 17
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
SYN POR PLUS HA SO STEM SZ 18
|
Facility
|
IP
|
$18,996.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,698.95 |
| Max. Negotiated Rate |
$18,236.64 |
| Rate for Payer: Aetna Commercial |
$14,627.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,817.27
|
| Rate for Payer: Cash Price |
$9,498.25
|
| Rate for Payer: Cigna Commercial |
$15,767.09
|
| Rate for Payer: First Health Commercial |
$18,046.67
|
| Rate for Payer: Humana Commercial |
$16,147.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,577.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,019.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,698.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,716.92
|
| Rate for Payer: Ohio Health Group HMO |
$14,247.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,197.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,526.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,107.58
|
| Rate for Payer: PHCS Commercial |
$18,236.64
|
| Rate for Payer: United Healthcare All Payer |
$16,716.92
|
|
|
SYN POR PLUS HA SO STEM SZ 18
|
Facility
|
OP
|
$18,996.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,698.95 |
| Max. Negotiated Rate |
$18,236.64 |
| Rate for Payer: Aetna Commercial |
$14,627.31
|
| Rate for Payer: Anthem Medicaid |
$6,532.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,817.27
|
| Rate for Payer: Cash Price |
$9,498.25
|
| Rate for Payer: Cigna Commercial |
$15,767.09
|
| Rate for Payer: First Health Commercial |
$18,046.67
|
| Rate for Payer: Humana Commercial |
$16,147.02
|
| Rate for Payer: Humana KY Medicaid |
$6,532.90
|
| Rate for Payer: Kentucky WC Medicaid |
$6,599.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,577.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,019.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,698.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,663.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,716.92
|
| Rate for Payer: Ohio Health Group HMO |
$14,247.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,197.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,526.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,107.58
|
| Rate for Payer: PHCS Commercial |
$18,236.64
|
| Rate for Payer: United Healthcare All Payer |
$16,716.92
|
|
|
SYN POR PLUS HA SO STEM SZ 8
|
Facility
|
IP
|
$20,642.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,192.71 |
| Max. Negotiated Rate |
$19,816.68 |
| Rate for Payer: Aetna Commercial |
$15,894.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,101.06
|
| Rate for Payer: Cash Price |
$10,321.19
|
| Rate for Payer: Cigna Commercial |
$17,133.18
|
| Rate for Payer: First Health Commercial |
$19,610.26
|
| Rate for Payer: Humana Commercial |
$17,546.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,926.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,234.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,192.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,165.29
|
| Rate for Payer: Ohio Health Group HMO |
$15,481.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,513.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,958.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,243.24
|
| Rate for Payer: PHCS Commercial |
$19,816.68
|
| Rate for Payer: United Healthcare All Payer |
$18,165.29
|
|
|
SYN POR PLUS HA SO STEM SZ 8
|
Facility
|
OP
|
$20,642.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,192.71 |
| Max. Negotiated Rate |
$19,816.68 |
| Rate for Payer: Aetna Commercial |
$15,894.63
|
| Rate for Payer: Anthem Medicaid |
$7,098.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,101.06
|
| Rate for Payer: Cash Price |
$10,321.19
|
| Rate for Payer: Cigna Commercial |
$17,133.18
|
| Rate for Payer: First Health Commercial |
$19,610.26
|
| Rate for Payer: Humana Commercial |
$17,546.02
|
| Rate for Payer: Humana KY Medicaid |
$7,098.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7,171.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,926.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,234.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,192.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,241.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,165.29
|
| Rate for Payer: Ohio Health Group HMO |
$15,481.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,513.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,958.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,243.24
|
| Rate for Payer: PHCS Commercial |
$19,816.68
|
| Rate for Payer: United Healthcare All Payer |
$18,165.29
|
|
|
SYN POR PLUS HA SO STEM SZ 9
|
Facility
|
OP
|
$20,642.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,192.71 |
| Max. Negotiated Rate |
$19,816.68 |
| Rate for Payer: Aetna Commercial |
$15,894.63
|
| Rate for Payer: Anthem Medicaid |
$7,098.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,101.06
|
| Rate for Payer: Cash Price |
$10,321.19
|
| Rate for Payer: Cigna Commercial |
$17,133.18
|
| Rate for Payer: First Health Commercial |
$19,610.26
|
| Rate for Payer: Humana Commercial |
$17,546.02
|
| Rate for Payer: Humana KY Medicaid |
$7,098.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7,171.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,926.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,234.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,192.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,241.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,165.29
|
| Rate for Payer: Ohio Health Group HMO |
$15,481.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,513.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,958.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,243.24
|
| Rate for Payer: PHCS Commercial |
$19,816.68
|
| Rate for Payer: United Healthcare All Payer |
$18,165.29
|
|
|
SYN POR PLUS HA SO STEM SZ 9
|
Facility
|
IP
|
$20,642.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,192.71 |
| Max. Negotiated Rate |
$19,816.68 |
| Rate for Payer: Aetna Commercial |
$15,894.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,101.06
|
| Rate for Payer: Cash Price |
$10,321.19
|
| Rate for Payer: Cigna Commercial |
$17,133.18
|
| Rate for Payer: First Health Commercial |
$19,610.26
|
| Rate for Payer: Humana Commercial |
$17,546.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,926.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,234.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,192.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,165.29
|
| Rate for Payer: Ohio Health Group HMO |
$15,481.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,513.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,958.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,243.24
|
| Rate for Payer: PHCS Commercial |
$19,816.68
|
| Rate for Payer: United Healthcare All Payer |
$18,165.29
|
|
|
SYNTHROID 0.025MG TAB
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
25001475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
SYNTHROID 0.025MG TAB
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
25001475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
SYNTHROID 10mcg(GEN) SDV
|
Facility
|
IP
|
$533.58
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
25003508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.07 |
| Max. Negotiated Rate |
$512.24 |
| Rate for Payer: Aetna Commercial |
$410.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.19
|
| Rate for Payer: Cash Price |
$266.79
|
| Rate for Payer: Cigna Commercial |
$442.87
|
| Rate for Payer: First Health Commercial |
$506.90
|
| Rate for Payer: Humana Commercial |
$453.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.55
|
| Rate for Payer: Ohio Health Group HMO |
$400.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.17
|
| Rate for Payer: PHCS Commercial |
$512.24
|
| Rate for Payer: United Healthcare All Payer |
$469.55
|
|
|
SYNTHROID 10mcg(GEN) SDV
|
Facility
|
OP
|
$533.58
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
25003508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.07 |
| Max. Negotiated Rate |
$512.24 |
| Rate for Payer: Aetna Commercial |
$410.86
|
| Rate for Payer: Anthem Medicaid |
$183.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.19
|
| Rate for Payer: Cash Price |
$266.79
|
| Rate for Payer: Cigna Commercial |
$442.87
|
| Rate for Payer: First Health Commercial |
$506.90
|
| Rate for Payer: Humana Commercial |
$453.54
|
| Rate for Payer: Humana KY Medicaid |
$183.50
|
| Rate for Payer: Kentucky WC Medicaid |
$185.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.55
|
| Rate for Payer: Ohio Health Group HMO |
$400.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.17
|
| Rate for Payer: PHCS Commercial |
$512.24
|
| Rate for Payer: United Healthcare All Payer |
$469.55
|
|
|
SYNTHROID 137MCG TABLET
|
Facility
|
IP
|
$4.92
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
25001476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna Commercial |
$3.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.67
|
| Rate for Payer: Humana Commercial |
$4.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.33
|
| Rate for Payer: Ohio Health Group HMO |
$3.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.39
|
| Rate for Payer: PHCS Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Payer |
$4.33
|
|
|
SYNTHROID 137MCG TABLET
|
Facility
|
OP
|
$4.92
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
25001476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna Commercial |
$3.79
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.67
|
| Rate for Payer: Humana Commercial |
$4.18
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.33
|
| Rate for Payer: Ohio Health Group HMO |
$3.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.39
|
| Rate for Payer: PHCS Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Payer |
$4.33
|
|
|
SYNTHROID 175 MCG TAB
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 60687054111
|
| Hospital Charge Code |
25004555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
SYNTHROID 175 MCG TAB
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
NDC 60687054111
|
| Hospital Charge Code |
25004555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
SYNTHROID 75 MCG TAB
|
Facility
|
IP
|
$4.79
|
|
|
Service Code
|
NDC 60687047501
|
| Hospital Charge Code |
25001469
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$3.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.55
|
| Rate for Payer: Humana Commercial |
$4.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.60
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
SYNTHROID 75 MCG TAB
|
Facility
|
OP
|
$4.79
|
|
|
Service Code
|
NDC 60687047501
|
| Hospital Charge Code |
25001469
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$3.69
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.55
|
| Rate for Payer: Humana Commercial |
$4.07
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.60
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
SYNTHROID (LEVOTHR 112MCG/1TAB
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
NDC 60687050801
|
| Hospital Charge Code |
25001470
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
