|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
761T0103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.05 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem Medicaid |
$175.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Humana KY Medicaid |
$175.05
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$176.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Professional
|
Both
|
$859.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
76100103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$515.40 |
| Rate for Payer: Aetna Commercial |
$95.92
|
| Rate for Payer: Ambetter Exchange |
$87.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.55
|
| Rate for Payer: Anthem Medicaid |
$33.67
|
| Rate for Payer: Buckeye Individual/Medicaid |
$87.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$104.41
|
| Rate for Payer: Cash Price |
$429.50
|
| Rate for Payer: Cash Price |
$429.50
|
| Rate for Payer: Cigna Commercial |
$153.14
|
| Rate for Payer: Healthspan PPO |
$139.17
|
| Rate for Payer: Humana Medicaid |
$33.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$82.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$87.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.34
|
| Rate for Payer: Molina Healthcare Passport |
$33.67
|
| Rate for Payer: Multiplan PHCS |
$515.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$113.11
|
| Rate for Payer: UHCCP Medicaid |
$48.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$34.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$87.01
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
45000041
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$175.05 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem Medicaid |
$175.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Humana KY Medicaid |
$175.05
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$176.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
45000041
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.70 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
WEDG EXC SKIN NAIL FOLDINGR NL
|
Facility
|
IP
|
$859.00
|
|
|
Service Code
|
HCPCS 11765
|
| Hospital Charge Code |
76100103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$257.70 |
| Max. Negotiated Rate |
$824.64 |
| Rate for Payer: Aetna Commercial |
$661.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$670.02
|
| Rate for Payer: Cash Price |
$429.50
|
| Rate for Payer: Cigna Commercial |
$712.97
|
| Rate for Payer: First Health Commercial |
$816.05
|
| Rate for Payer: Humana Commercial |
$730.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$704.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.92
|
| Rate for Payer: Ohio Health Group HMO |
$644.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$687.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$747.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.71
|
| Rate for Payer: PHCS Commercial |
$824.64
|
| Rate for Payer: United Healthcare All Payer |
$755.92
|
|
|
WEEKLY PHYSICS
|
Facility
|
IP
|
$784.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
33300017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$235.20 |
| Max. Negotiated Rate |
$752.64 |
| Rate for Payer: Aetna Commercial |
$603.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$611.52
|
| Rate for Payer: Cash Price |
$392.00
|
| Rate for Payer: Cigna Commercial |
$650.72
|
| Rate for Payer: First Health Commercial |
$744.80
|
| Rate for Payer: Humana Commercial |
$666.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$642.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$578.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$689.92
|
| Rate for Payer: Ohio Health Group HMO |
$588.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$627.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$540.96
|
| Rate for Payer: PHCS Commercial |
$752.64
|
| Rate for Payer: United Healthcare All Payer |
$689.92
|
|
|
WEEKLY PHYSICS
|
Professional
|
Both
|
$784.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
33300017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$470.40 |
| Rate for Payer: Aetna Commercial |
$95.94
|
| Rate for Payer: Ambetter Exchange |
$81.02
|
| Rate for Payer: Anthem Medicaid |
$80.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$81.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$81.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$97.22
|
| Rate for Payer: Cash Price |
$392.00
|
| Rate for Payer: Cash Price |
$392.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$81.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.16
|
| Rate for Payer: Molina Healthcare Passport |
$80.55
|
| Rate for Payer: Multiplan PHCS |
$470.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.33
|
| Rate for Payer: UHCCP Medicaid |
$274.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$81.02
|
|
|
WEEKLY PHYSICS
|
Facility
|
OP
|
$784.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
33300017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$752.64 |
| Rate for Payer: Aetna Commercial |
$603.68
|
| Rate for Payer: Anthem Medicaid |
$269.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$122.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$611.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$171.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.62
|
| Rate for Payer: Cash Price |
$392.00
|
| Rate for Payer: Cash Price |
$392.00
|
| Rate for Payer: Cigna Commercial |
$650.72
|
| Rate for Payer: First Health Commercial |
$744.80
|
| Rate for Payer: Humana Commercial |
$666.40
|
| Rate for Payer: Humana KY Medicaid |
$269.62
|
| Rate for Payer: Humana Medicare Advantage |
$122.68
|
| Rate for Payer: Kentucky WC Medicaid |
$272.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$642.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$578.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$689.92
|
| Rate for Payer: Ohio Health Group HMO |
$588.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$627.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$540.96
|
| Rate for Payer: PHCS Commercial |
$752.64
|
| Rate for Payer: United Healthcare All Payer |
$689.92
|
|
|
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 |
$150.00 |
| Rate for Payer: Aetna Commercial |
$95.94
|
| Rate for Payer: Ambetter Exchange |
$81.02
|
| Rate for Payer: Anthem Medicaid |
$80.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$81.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$81.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$97.22
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$81.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.02
|
| 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 |
$105.33
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$81.02
|
|
|
WEEKLY PHYSICS(T
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
333T0017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$160.20 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.46
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
WEEKLY PHYSICS(T
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS 77336
|
| Hospital Charge Code |
333T0017
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem Medicaid |
$183.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$122.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$171.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.62
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Humana KY Medicaid |
$183.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.68
|
| Rate for Payer: Kentucky WC Medicaid |
$185.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.46
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
WELCHOL(COLESEV HCL)625MG TAB
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 69452015825
|
| Hospital Charge Code |
25001716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
WELCHOL(COLESEV HCL)625MG TAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 69452015825
|
| Hospital Charge Code |
25001716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| 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 |
$2.93 |
| 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 |
$7.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.74
|
| 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 |
$2.93 |
| 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 |
$7.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.74
|
| 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 |
$1.54 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| 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 |
$4.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.54
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
WELLBUTRIN(BUPROPION 75MG/1TAB
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 50268014215
|
| Hospital Charge Code |
25001721
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| 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 |
$4.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.54
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
WELLBUTRIN CR 150 MG TABLET
|
Facility
|
IP
|
$4.81
|
|
|
Service Code
|
NDC 68084070825
|
| Hospital Charge Code |
25001717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.99
|
| Rate for Payer: First Health Commercial |
$4.57
|
| Rate for Payer: Humana Commercial |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.23
|
| Rate for Payer: Ohio Health Group HMO |
$3.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.32
|
| Rate for Payer: PHCS Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$4.23
|
|
|
WELLBUTRIN CR 150 MG TABLET
|
Facility
|
OP
|
$4.81
|
|
|
Service Code
|
NDC 68084070825
|
| Hospital Charge Code |
25001717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.99
|
| Rate for Payer: First Health Commercial |
$4.57
|
| Rate for Payer: Humana Commercial |
$4.09
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.23
|
| Rate for Payer: Ohio Health Group HMO |
$3.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.32
|
| Rate for Payer: PHCS Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$4.23
|
|
|
WELLBUTRIN SR 100MG TAB
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 70436005801
|
| Hospital Charge Code |
25001718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| 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 |
$1.33 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| 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 |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
WET PREP - W/INTERPRETATION
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
30001336
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$5.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$5.82
|
| Rate for Payer: Humana Medicare Advantage |
$5.82
|
| Rate for Payer: Kentucky WC Medicaid |
$5.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
WET PREP - W/INTERPRETATION
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
30001336
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$7.68
|
| Rate for Payer: Ambetter Exchange |
$5.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$5.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$5.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.98
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$6.12
|
| Rate for Payer: Healthspan PPO |
$4.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$5.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.82
|
| Rate for Payer: Multiplan PHCS |
$43.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7.57
|
| Rate for Payer: UHCCP Medicaid |
$25.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$5.82
|
|
