|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
IP
|
$828.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
76100103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.64 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$637.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$645.84
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: First Health Commercial |
$786.60
|
| Rate for Payer: Humana Commercial |
$703.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$678.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$611.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$248.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$728.64
|
| Rate for Payer: Ohio Health Group HMO |
$621.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$256.68
|
| Rate for Payer: PHCS Commercial |
$794.88
|
| Rate for Payer: United Healthcare All Payer |
$728.64
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
IP
|
$478.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
45000041
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$458.88 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.18
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
OP
|
$828.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
76100103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.64 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$637.56
|
| Rate for Payer: Anthem Medicaid |
$284.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$645.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: First Health Commercial |
$786.60
|
| Rate for Payer: Humana Commercial |
$703.80
|
| Rate for Payer: Humana KY Medicaid |
$284.75
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$287.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$678.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$611.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$290.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$728.64
|
| Rate for Payer: Ohio Health Group HMO |
$621.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$256.68
|
| Rate for Payer: PHCS Commercial |
$794.88
|
| Rate for Payer: United Healthcare All Payer |
$728.64
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
OP
|
$478.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
45000041
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem Medicaid |
$164.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Humana KY Medicaid |
$164.38
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$166.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$167.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.18
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
OP
|
$478.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
761T0103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem Medicaid |
$164.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Humana KY Medicaid |
$164.38
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$166.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$167.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.18
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Professional
|
Both
|
$828.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
76100103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.83 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna Commercial |
$95.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.55
|
| Rate for Payer: Anthem Medicaid |
$26.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$828.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$153.14
|
| Rate for Payer: Healthspan PPO |
$139.17
|
| Rate for Payer: Humana Medicaid |
$26.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$82.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.37
|
| Rate for Payer: Molina Healthcare Passport |
$26.83
|
| Rate for Payer: Multiplan PHCS |
$496.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$579.60
|
| Rate for Payer: UHCCP Medicaid |
$48.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.10
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
IP
|
$478.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
761T0103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$458.88 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.18
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
WEEKLY PHYSICS
|
Facility
|
OP
|
$769.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
33300017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$99.97 |
| Max. Negotiated Rate |
$738.24 |
| Rate for Payer: Aetna Commercial |
$592.13
|
| Rate for Payer: Anthem Medicaid |
$264.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$117.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$164.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.40
|
| Rate for Payer: Cash Price |
$384.50
|
| Rate for Payer: Cash Price |
$384.50
|
| Rate for Payer: Cigna Commercial |
$638.27
|
| Rate for Payer: First Health Commercial |
$730.55
|
| Rate for Payer: Humana Commercial |
$653.65
|
| Rate for Payer: Humana KY Medicaid |
$264.46
|
| Rate for Payer: Humana Medicare Advantage |
$117.33
|
| Rate for Payer: Kentucky WC Medicaid |
$267.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$630.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$567.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$676.72
|
| Rate for Payer: Ohio Health Group HMO |
$576.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.39
|
| Rate for Payer: PHCS Commercial |
$738.24
|
| Rate for Payer: United Healthcare All Payer |
$676.72
|
|
|
WEEKLY PHYSICS
|
Facility
|
IP
|
$769.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
33300017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$99.97 |
| Max. Negotiated Rate |
$738.24 |
| Rate for Payer: Aetna Commercial |
$592.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.82
|
| Rate for Payer: Cash Price |
$384.50
|
| Rate for Payer: Cigna Commercial |
$638.27
|
| Rate for Payer: First Health Commercial |
$730.55
|
| Rate for Payer: Humana Commercial |
$653.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$630.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$567.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$676.72
|
| Rate for Payer: Ohio Health Group HMO |
$576.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.39
|
| Rate for Payer: PHCS Commercial |
$738.24
|
| Rate for Payer: United Healthcare All Payer |
$676.72
|
|
|
WEEKLY PHYSICS
|
Professional
|
Both
|
$769.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
33300017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$769.00 |
| Rate for Payer: Aetna Commercial |
$95.94
|
| Rate for Payer: Anthem Medicaid |
$80.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$769.00
|
| Rate for Payer: Cash Price |
$384.50
|
| Rate for Payer: Cash Price |
$384.50
|
| Rate for Payer: Cigna Commercial |
$148.03
|
| Rate for Payer: Healthspan PPO |
$80.91
|
| Rate for Payer: Humana Medicaid |
$80.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.16
|
| Rate for Payer: Molina Healthcare Passport |
$80.55
|
| Rate for Payer: Multiplan PHCS |
$461.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$538.30
|
| Rate for Payer: UHCCP Medicaid |
$269.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.36
|
|
|
WEEKLY PHYSICS(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
333P0017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$95.94
|
| Rate for Payer: Anthem Medicaid |
$80.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$148.03
|
| Rate for Payer: Healthspan PPO |
$80.91
|
| Rate for Payer: Humana Medicaid |
$80.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.16
|
| Rate for Payer: Molina Healthcare Passport |
$80.55
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.36
|
|
|
WEEKLY PHYSICS(T
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
333T0017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem Medicaid |
$178.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$117.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$164.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.40
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Humana KY Medicaid |
$178.48
|
| Rate for Payer: Humana Medicare Advantage |
$117.33
|
| Rate for Payer: Kentucky WC Medicaid |
$180.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
WEEKLY PHYSICS(T
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
333T0017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
WELCHOL(COLESEV HCL)625MG TAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 69452015825
|
| Hospital Charge Code |
25001716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
WELCHOL(COLESEV HCL)625MG TAB
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 69452015825
|
| Hospital Charge Code |
25001716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
WELLBUTRIN(BUPROPIO 100MG/1TAB
|
Facility
|
IP
|
$9.77
|
|
|
Service Code
|
NDC 50268014315
|
| Hospital Charge Code |
25001720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Cigna Commercial |
$8.11
|
| Rate for Payer: First Health Commercial |
$9.28
|
| Rate for Payer: Humana Commercial |
$8.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.60
|
| Rate for Payer: Ohio Health Group HMO |
$7.33
|
| 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 |
$3.03
|
| Rate for Payer: PHCS Commercial |
$9.38
|
| Rate for Payer: United Healthcare All Payer |
$8.60
|
|
|
WELLBUTRIN(BUPROPIO 100MG/1TAB
|
Facility
|
OP
|
$9.77
|
|
|
Service Code
|
NDC 50268014315
|
| Hospital Charge Code |
25001720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Anthem Medicaid |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Cigna Commercial |
$8.11
|
| Rate for Payer: First Health Commercial |
$9.28
|
| Rate for Payer: Humana Commercial |
$8.30
|
| Rate for Payer: Humana KY Medicaid |
$3.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.60
|
| Rate for Payer: Ohio Health Group HMO |
$7.33
|
| 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 |
$3.03
|
| Rate for Payer: PHCS Commercial |
$9.38
|
| Rate for Payer: United Healthcare All Payer |
$8.60
|
|
|
WELLBUTRIN(BUPROPION 75MG/1TAB
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 50268014215
|
| Hospital Charge Code |
25001721
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Anthem Medicaid |
$1.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.26
|
| Rate for Payer: First Health Commercial |
$4.87
|
| Rate for Payer: Humana Commercial |
$4.36
|
| Rate for Payer: Humana KY Medicaid |
$1.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.51
|
| Rate for Payer: Ohio Health Group HMO |
$3.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.59
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
| Rate for Payer: Aetna Commercial |
$3.95
|
|
|
WELLBUTRIN(BUPROPION 75MG/1TAB
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 50268014215
|
| Hospital Charge Code |
25001721
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.26
|
| Rate for Payer: First Health Commercial |
$4.87
|
| Rate for Payer: Humana Commercial |
$4.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.51
|
| Rate for Payer: Ohio Health Group HMO |
$3.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.59
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
WELLBUTRIN CR 150 MG TABLET
|
Facility
|
OP
|
$4.79
|
|
|
Service Code
|
NDC 904721461
|
| Hospital Charge Code |
25001717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| 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 |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.60
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
WELLBUTRIN CR 150 MG TABLET
|
Facility
|
IP
|
$4.79
|
|
|
Service Code
|
NDC 904721461
|
| Hospital Charge Code |
25001717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| 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 |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.60
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
WELLBUTRIN SR 100MG TAB
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 70436005801
|
| Hospital Charge Code |
25001718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
WELLBUTRIN SR 100MG TAB
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 70436005801
|
| Hospital Charge Code |
25001718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
WELLBUTRIN XL(BUPROPHCL)150MGT
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 16729044315
|
| Hospital Charge Code |
25001719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
WELLBUTRIN XL(BUPROPHCL)150MGT
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 16729044315
|
| Hospital Charge Code |
25001719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
