|
Brief check in by md/qhp
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS G2012
|
| Hospital Charge Code |
510T0021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$27.84 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.62
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cigna Commercial |
$24.07
|
| Rate for Payer: First Health Commercial |
$27.55
|
| Rate for Payer: Humana Commercial |
$24.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.52
|
| Rate for Payer: Ohio Health Group HMO |
$21.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.99
|
| Rate for Payer: PHCS Commercial |
$27.84
|
| Rate for Payer: United Healthcare All Payer |
$25.52
|
|
|
Brief check in by md/qhp
|
Professional
|
Both
|
$50.00
|
|
| Hospital Charge Code |
51000021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$50.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
|
|
Brief check in by md/qhp
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS G2012
|
| Hospital Charge Code |
510T0021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$27.84 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Anthem Medicaid |
$9.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.62
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cigna Commercial |
$24.07
|
| Rate for Payer: First Health Commercial |
$27.55
|
| Rate for Payer: Humana Commercial |
$24.65
|
| Rate for Payer: Humana KY Medicaid |
$9.97
|
| Rate for Payer: Kentucky WC Medicaid |
$10.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.52
|
| Rate for Payer: Ohio Health Group HMO |
$21.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.99
|
| Rate for Payer: PHCS Commercial |
$27.84
|
| Rate for Payer: United Healthcare All Payer |
$25.52
|
|
|
Brief check in by md/qhp
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
HCPCS G2012
|
| Hospital Charge Code |
510P0021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$10.41
|
| Rate for Payer: Anthem Medicaid |
$10.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$21.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Humana Medicaid |
$10.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$17.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$10.60
|
| Rate for Payer: Molina Healthcare Passport |
$10.39
|
| Rate for Payer: Multiplan PHCS |
$12.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.70
|
| Rate for Payer: UHCCP Medicaid |
$10.93
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.49
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
51000048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$80.85
|
| Rate for Payer: Anthem Medicaid |
$36.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$87.15
|
| Rate for Payer: First Health Commercial |
$99.75
|
| Rate for Payer: Humana Commercial |
$89.25
|
| Rate for Payer: Humana KY Medicaid |
$36.11
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$36.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$77.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$92.40
|
| Rate for Payer: Ohio Health Group HMO |
$78.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.55
|
| Rate for Payer: PHCS Commercial |
$100.80
|
| Rate for Payer: United Healthcare All Payer |
$92.40
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
51000048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$80.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.90
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$87.15
|
| Rate for Payer: First Health Commercial |
$99.75
|
| Rate for Payer: Humana Commercial |
$89.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$77.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$92.40
|
| Rate for Payer: Ohio Health Group HMO |
$78.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.55
|
| Rate for Payer: PHCS Commercial |
$100.80
|
| Rate for Payer: United Healthcare All Payer |
$92.40
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
51000048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Anthem Medicaid |
$3.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$105.00
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$7.20
|
| Rate for Payer: Humana Medicaid |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3.94
|
| Rate for Payer: Molina Healthcare Passport |
$3.86
|
| Rate for Payer: Multiplan PHCS |
$63.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.50
|
| Rate for Payer: UHCCP Medicaid |
$36.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.90
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT(P
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
510P0048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Anthem Medicaid |
$3.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.00
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$7.20
|
| Rate for Payer: Humana Medicaid |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3.94
|
| Rate for Payer: Molina Healthcare Passport |
$3.86
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.50
|
| Rate for Payer: UHCCP Medicaid |
$19.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.90
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT(T
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
510T0048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$48.55 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem Medicaid |
$17.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Humana KY Medicaid |
$17.20
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$17.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT(T
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
510T0048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
BRIGHTAMIN C
|
Professional
|
Both
|
$145.00
|
|
| Hospital Charge Code |
22200124
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$145.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$145.00
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$87.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.50
|
| Rate for Payer: UHCCP Medicaid |
$50.75
|
|
|
BRIGHT NON-RETINOL SK BRIGHT
|
Professional
|
Both
|
$120.00
|
|
| Hospital Charge Code |
22200159
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
|
|
BRILINTA 60MG TABLET
|
Facility
|
IP
|
$24.52
|
|
|
Service Code
|
NDC 186077660
|
| Hospital Charge Code |
25003874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna Commercial |
$18.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.13
|
| Rate for Payer: Cash Price |
$12.26
|
| Rate for Payer: Cigna Commercial |
$20.35
|
| Rate for Payer: First Health Commercial |
$23.29
|
| Rate for Payer: Humana Commercial |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.58
|
| Rate for Payer: Ohio Health Group HMO |
$18.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.60
|
| Rate for Payer: PHCS Commercial |
$23.54
|
| Rate for Payer: United Healthcare All Payer |
$21.58
|
|
|
BRILINTA 60MG TABLET
|
Facility
|
OP
|
$24.52
|
|
|
Service Code
|
NDC 186077660
|
| Hospital Charge Code |
25003874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna Commercial |
$18.88
|
| Rate for Payer: Anthem Medicaid |
$8.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.13
|
| Rate for Payer: Cash Price |
$12.26
|
| Rate for Payer: Cigna Commercial |
$20.35
|
| Rate for Payer: First Health Commercial |
$23.29
|
| Rate for Payer: Humana Commercial |
$20.84
|
| Rate for Payer: Humana KY Medicaid |
$8.43
|
| Rate for Payer: Kentucky WC Medicaid |
$8.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.58
|
| Rate for Payer: Ohio Health Group HMO |
$18.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.60
|
| Rate for Payer: PHCS Commercial |
$23.54
|
| Rate for Payer: United Healthcare All Payer |
$21.58
|
|
|
BRILINTA 90MG TABLET
|
Facility
|
IP
|
$24.52
|
|
|
Service Code
|
NDC 186077739
|
| Hospital Charge Code |
25000346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna Commercial |
$18.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.13
|
| Rate for Payer: Cash Price |
$12.26
|
| Rate for Payer: Cigna Commercial |
$20.35
|
| Rate for Payer: First Health Commercial |
$23.29
|
| Rate for Payer: Humana Commercial |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.58
|
| Rate for Payer: Ohio Health Group HMO |
$18.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.60
|
| Rate for Payer: PHCS Commercial |
$23.54
|
| Rate for Payer: United Healthcare All Payer |
$21.58
|
|
|
BRILINTA 90MG TABLET
|
Facility
|
OP
|
$24.52
|
|
|
Service Code
|
NDC 186077739
|
| Hospital Charge Code |
25000346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna Commercial |
$18.88
|
| Rate for Payer: Anthem Medicaid |
$8.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.13
|
| Rate for Payer: Cash Price |
$12.26
|
| Rate for Payer: Cigna Commercial |
$20.35
|
| Rate for Payer: First Health Commercial |
$23.29
|
| Rate for Payer: Humana Commercial |
$20.84
|
| Rate for Payer: Humana KY Medicaid |
$8.43
|
| Rate for Payer: Kentucky WC Medicaid |
$8.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.58
|
| Rate for Payer: Ohio Health Group HMO |
$18.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.60
|
| Rate for Payer: PHCS Commercial |
$23.54
|
| Rate for Payer: United Healthcare All Payer |
$21.58
|
|
|
BRIMOIDINE 0.2% 5ML (PER DROP)
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
25000198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Aetna Commercial |
$62.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.27
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cash Price |
$40.56
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: Cigna Commercial |
$67.32
|
| Rate for Payer: First Health Commercial |
$77.05
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$68.94
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group HMO |
$60.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: PHCS Commercial |
$77.87
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
| Rate for Payer: United Healthcare All Payer |
$71.38
|
|
|
BRIMOIDINE 0.2% 5ML (PER DROP)
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
25000198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.27
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cash Price |
$40.56
|
| Rate for Payer: Cigna Commercial |
$67.32
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$77.05
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana Commercial |
$68.94
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Humana KY Medicaid |
$27.89
|
| Rate for Payer: Kentucky WC Medicaid |
$28.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.51
|
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Aetna Commercial |
$62.45
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem Medicaid |
$27.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group HMO |
$60.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.14
|
| Rate for Payer: PHCS Commercial |
$77.87
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$71.38
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
BRIVARACETAM 50mg SDV
|
Facility
|
IP
|
$335.67
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004432
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.64 |
| Max. Negotiated Rate |
$322.24 |
| Rate for Payer: Aetna Commercial |
$258.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.82
|
| Rate for Payer: Cash Price |
$167.84
|
| Rate for Payer: Cigna Commercial |
$278.61
|
| Rate for Payer: First Health Commercial |
$318.89
|
| Rate for Payer: Humana Commercial |
$285.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$275.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$295.39
|
| Rate for Payer: Ohio Health Group HMO |
$251.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.06
|
| Rate for Payer: PHCS Commercial |
$322.24
|
| Rate for Payer: United Healthcare All Payer |
$295.39
|
|
|
BRIVARACETAM 50mg SDV
|
Facility
|
OP
|
$335.67
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004432
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.64 |
| Max. Negotiated Rate |
$322.24 |
| Rate for Payer: Aetna Commercial |
$258.47
|
| Rate for Payer: Anthem Medicaid |
$115.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.82
|
| Rate for Payer: Cash Price |
$167.84
|
| Rate for Payer: Cigna Commercial |
$278.61
|
| Rate for Payer: First Health Commercial |
$318.89
|
| Rate for Payer: Humana Commercial |
$285.32
|
| Rate for Payer: Humana KY Medicaid |
$115.44
|
| Rate for Payer: Kentucky WC Medicaid |
$116.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$275.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$295.39
|
| Rate for Payer: Ohio Health Group HMO |
$251.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.06
|
| Rate for Payer: PHCS Commercial |
$322.24
|
| Rate for Payer: United Healthcare All Payer |
$295.39
|
|
|
BRNCHSC W/THER ASPIR 1ST
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
41000052
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$74.06 |
| Max. Negotiated Rate |
$377.41 |
| Rate for Payer: Aetna Commercial |
$268.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$74.06
|
| Rate for Payer: Anthem Medicaid |
$197.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$335.00
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$243.04
|
| Rate for Payer: Healthspan PPO |
$377.41
|
| Rate for Payer: Humana Medicaid |
$197.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$206.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.05
|
| Rate for Payer: Molina Healthcare Passport |
$197.11
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$234.50
|
| Rate for Payer: UHCCP Medicaid |
$77.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.08
|
|
|
BRNCHSC W/THER ASPIR 1ST(P
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
410P0052
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$74.06 |
| Max. Negotiated Rate |
$377.41 |
| Rate for Payer: Aetna Commercial |
$268.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$74.06
|
| Rate for Payer: Anthem Medicaid |
$197.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$335.00
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$243.04
|
| Rate for Payer: Healthspan PPO |
$377.41
|
| Rate for Payer: Humana Medicaid |
$197.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$206.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.05
|
| Rate for Payer: Molina Healthcare Passport |
$197.11
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$234.50
|
| Rate for Payer: UHCCP Medicaid |
$77.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.08
|
|
|
BRNCHSC W/THER ASPIR SBSQ
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
HCPCS 31646
|
| Hospital Charge Code |
41000053
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$342.14 |
| Rate for Payer: Aetna Commercial |
$232.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$71.64
|
| Rate for Payer: Anthem Medicaid |
$168.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$304.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$211.45
|
| Rate for Payer: Healthspan PPO |
$342.14
|
| Rate for Payer: Humana Medicaid |
$168.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$179.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.82
|
| Rate for Payer: Molina Healthcare Passport |
$168.45
|
| Rate for Payer: Multiplan PHCS |
$182.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.80
|
| Rate for Payer: UHCCP Medicaid |
$75.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.13
|
|
|
BRNCHSC W/THER ASPIR SBSQ(P
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
HCPCS 31646
|
| Hospital Charge Code |
410P0053
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$342.14 |
| Rate for Payer: Aetna Commercial |
$232.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$71.64
|
| Rate for Payer: Anthem Medicaid |
$168.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$304.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$211.45
|
| Rate for Payer: Healthspan PPO |
$342.14
|
| Rate for Payer: Humana Medicaid |
$168.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$179.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.82
|
| Rate for Payer: Molina Healthcare Passport |
$168.45
|
| Rate for Payer: Multiplan PHCS |
$182.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.80
|
| Rate for Payer: UHCCP Medicaid |
$75.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.13
|
|
|
BROCHE KIRSCHNER 1.5MM LG 150
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.78
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
