|
EMP STEM 23 LNG REV POL +20 R
|
Facility
|
IP
|
$26,703.69
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,011.11 |
| Max. Negotiated Rate |
$25,635.54 |
| Rate for Payer: Aetna Commercial |
$20,561.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,828.88
|
| Rate for Payer: Cash Price |
$13,351.84
|
| Rate for Payer: Cigna Commercial |
$22,164.06
|
| Rate for Payer: First Health Commercial |
$25,368.51
|
| Rate for Payer: Humana Commercial |
$22,698.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,897.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,707.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,011.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,499.25
|
| Rate for Payer: Ohio Health Group HMO |
$20,027.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,362.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,232.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,425.55
|
| Rate for Payer: PHCS Commercial |
$25,635.54
|
| Rate for Payer: United Healthcare All Payer |
$23,499.25
|
|
|
EMP STEM 23 SH REV POL +0
|
Facility
|
IP
|
$11,966.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,589.90 |
| Max. Negotiated Rate |
$11,487.67 |
| Rate for Payer: Aetna Commercial |
$9,214.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,333.73
|
| Rate for Payer: Cash Price |
$5,983.16
|
| Rate for Payer: Cigna Commercial |
$9,932.05
|
| Rate for Payer: First Health Commercial |
$11,368.00
|
| Rate for Payer: Humana Commercial |
$10,171.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,812.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,831.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,589.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,530.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,974.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,573.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,410.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,256.76
|
| Rate for Payer: PHCS Commercial |
$11,487.67
|
| Rate for Payer: United Healthcare All Payer |
$10,530.36
|
|
|
EMP STEM 23 SH REV POL +0
|
Facility
|
OP
|
$11,966.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,589.90 |
| Max. Negotiated Rate |
$11,487.67 |
| Rate for Payer: Aetna Commercial |
$9,214.07
|
| Rate for Payer: Anthem Medicaid |
$4,115.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,333.73
|
| Rate for Payer: Cash Price |
$5,983.16
|
| Rate for Payer: Cigna Commercial |
$9,932.05
|
| Rate for Payer: First Health Commercial |
$11,368.00
|
| Rate for Payer: Humana Commercial |
$10,171.37
|
| Rate for Payer: Humana KY Medicaid |
$4,115.22
|
| Rate for Payer: Kentucky WC Medicaid |
$4,157.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,812.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,831.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,589.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,197.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,530.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,974.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,573.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,410.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,256.76
|
| Rate for Payer: PHCS Commercial |
$11,487.67
|
| Rate for Payer: United Healthcare All Payer |
$10,530.36
|
|
|
EMP STEM 23 SH REV POL +10
|
Facility
|
OP
|
$11,966.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,589.90 |
| Max. Negotiated Rate |
$11,487.67 |
| Rate for Payer: Aetna Commercial |
$9,214.07
|
| Rate for Payer: Anthem Medicaid |
$4,115.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,333.73
|
| Rate for Payer: Cash Price |
$5,983.16
|
| Rate for Payer: Cigna Commercial |
$9,932.05
|
| Rate for Payer: First Health Commercial |
$11,368.00
|
| Rate for Payer: Humana Commercial |
$10,171.37
|
| Rate for Payer: Humana KY Medicaid |
$4,115.22
|
| Rate for Payer: Kentucky WC Medicaid |
$4,157.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,812.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,831.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,589.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,197.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,530.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,974.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,573.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,410.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,256.76
|
| Rate for Payer: PHCS Commercial |
$11,487.67
|
| Rate for Payer: United Healthcare All Payer |
$10,530.36
|
|
|
EMP STEM 23 SH REV POL +10
|
Facility
|
IP
|
$11,966.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,589.90 |
| Max. Negotiated Rate |
$11,487.67 |
| Rate for Payer: Aetna Commercial |
$9,214.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,333.73
|
| Rate for Payer: Cash Price |
$5,983.16
|
| Rate for Payer: Cigna Commercial |
$9,932.05
|
| Rate for Payer: First Health Commercial |
$11,368.00
|
| Rate for Payer: Humana Commercial |
$10,171.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,812.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,831.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,589.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,530.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,974.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,573.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,410.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,256.76
|
| Rate for Payer: PHCS Commercial |
$11,487.67
|
| Rate for Payer: United Healthcare All Payer |
$10,530.36
|
|
|
EMP STEM 9 RO 140MM
|
Facility
|
OP
|
$18,253.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,476.12 |
| Max. Negotiated Rate |
$17,523.57 |
| Rate for Payer: Aetna Commercial |
$14,055.36
|
| Rate for Payer: Anthem Medicaid |
$6,277.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.90
|
| Rate for Payer: Cash Price |
$9,126.86
|
| Rate for Payer: Cigna Commercial |
$15,150.59
|
| Rate for Payer: First Health Commercial |
$17,341.03
|
| Rate for Payer: Humana Commercial |
$15,515.66
|
| Rate for Payer: Humana KY Medicaid |
$6,277.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,341.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,968.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,471.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,476.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,403.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,063.27
|
| Rate for Payer: Ohio Health Group HMO |
$13,690.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,880.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,595.07
|
| Rate for Payer: PHCS Commercial |
$17,523.57
|
| Rate for Payer: United Healthcare All Payer |
$16,063.27
|
|
|
EMP STEM 9 RO 140MM
|
Facility
|
IP
|
$18,253.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,476.12 |
| Max. Negotiated Rate |
$17,523.57 |
| Rate for Payer: Aetna Commercial |
$14,055.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.90
|
| Rate for Payer: Cash Price |
$9,126.86
|
| Rate for Payer: Cigna Commercial |
$15,150.59
|
| Rate for Payer: First Health Commercial |
$17,341.03
|
| Rate for Payer: Humana Commercial |
$15,515.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,968.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,471.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,476.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,063.27
|
| Rate for Payer: Ohio Health Group HMO |
$13,690.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,880.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,595.07
|
| Rate for Payer: PHCS Commercial |
$17,523.57
|
| Rate for Payer: United Healthcare All Payer |
$16,063.27
|
|
|
EMP STEM 9 SO 140MM
|
Facility
|
IP
|
$18,253.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,476.12 |
| Max. Negotiated Rate |
$17,523.57 |
| Rate for Payer: Aetna Commercial |
$14,055.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.90
|
| Rate for Payer: Cash Price |
$9,126.86
|
| Rate for Payer: Cigna Commercial |
$15,150.59
|
| Rate for Payer: First Health Commercial |
$17,341.03
|
| Rate for Payer: Humana Commercial |
$15,515.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,968.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,471.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,476.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,063.27
|
| Rate for Payer: Ohio Health Group HMO |
$13,690.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,880.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,595.07
|
| Rate for Payer: PHCS Commercial |
$17,523.57
|
| Rate for Payer: United Healthcare All Payer |
$16,063.27
|
|
|
EMP STEM 9 SO 140MM
|
Facility
|
OP
|
$18,253.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,476.12 |
| Max. Negotiated Rate |
$17,523.57 |
| Rate for Payer: Aetna Commercial |
$14,055.36
|
| Rate for Payer: Anthem Medicaid |
$6,277.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.90
|
| Rate for Payer: Cash Price |
$9,126.86
|
| Rate for Payer: Cigna Commercial |
$15,150.59
|
| Rate for Payer: First Health Commercial |
$17,341.03
|
| Rate for Payer: Humana Commercial |
$15,515.66
|
| Rate for Payer: Humana KY Medicaid |
$6,277.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,341.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,968.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,471.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,476.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,403.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,063.27
|
| Rate for Payer: Ohio Health Group HMO |
$13,690.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,880.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,595.07
|
| Rate for Payer: PHCS Commercial |
$17,523.57
|
| Rate for Payer: United Healthcare All Payer |
$16,063.27
|
|
|
EMSAM(SELEGILINE)24HR 6MG PTCH
|
Facility
|
OP
|
$147.07
|
|
|
Service Code
|
NDC 49502090030
|
| Hospital Charge Code |
25000618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$141.19 |
| Rate for Payer: Aetna Commercial |
$113.24
|
| Rate for Payer: Anthem Medicaid |
$50.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.71
|
| Rate for Payer: Cash Price |
$73.53
|
| Rate for Payer: Cigna Commercial |
$122.07
|
| Rate for Payer: First Health Commercial |
$139.72
|
| Rate for Payer: Humana Commercial |
$125.01
|
| Rate for Payer: Humana KY Medicaid |
$50.58
|
| Rate for Payer: Kentucky WC Medicaid |
$51.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.42
|
| Rate for Payer: Ohio Health Group HMO |
$110.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.48
|
| Rate for Payer: PHCS Commercial |
$141.19
|
| Rate for Payer: United Healthcare All Payer |
$129.42
|
|
|
EMSAM(SELEGILINE)24HR 6MG PTCH
|
Facility
|
IP
|
$147.07
|
|
|
Service Code
|
NDC 49502090030
|
| Hospital Charge Code |
25000618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$141.19 |
| Rate for Payer: Aetna Commercial |
$113.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.71
|
| Rate for Payer: Cash Price |
$73.53
|
| Rate for Payer: Cigna Commercial |
$122.07
|
| Rate for Payer: First Health Commercial |
$139.72
|
| Rate for Payer: Humana Commercial |
$125.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.42
|
| Rate for Payer: Ohio Health Group HMO |
$110.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.48
|
| Rate for Payer: PHCS Commercial |
$141.19
|
| Rate for Payer: United Healthcare All Payer |
$129.42
|
|
|
EMTRIVA 200 MG CAPSULE
|
Facility
|
IP
|
$34.88
|
|
|
Service Code
|
NDC 61958060101
|
| Hospital Charge Code |
25003036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$33.48 |
| Rate for Payer: Aetna Commercial |
$26.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.21
|
| Rate for Payer: Cash Price |
$17.44
|
| Rate for Payer: Cigna Commercial |
$28.95
|
| Rate for Payer: First Health Commercial |
$33.14
|
| Rate for Payer: Humana Commercial |
$29.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.69
|
| Rate for Payer: Ohio Health Group HMO |
$26.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.07
|
| Rate for Payer: PHCS Commercial |
$33.48
|
| Rate for Payer: United Healthcare All Payer |
$30.69
|
|
|
EMTRIVA 200 MG CAPSULE
|
Facility
|
OP
|
$34.88
|
|
|
Service Code
|
NDC 61958060101
|
| Hospital Charge Code |
25003036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$33.48 |
| Rate for Payer: Aetna Commercial |
$26.86
|
| Rate for Payer: Anthem Medicaid |
$12.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.21
|
| Rate for Payer: Cash Price |
$17.44
|
| Rate for Payer: Cigna Commercial |
$28.95
|
| Rate for Payer: First Health Commercial |
$33.14
|
| Rate for Payer: Humana Commercial |
$29.65
|
| Rate for Payer: Humana KY Medicaid |
$12.00
|
| Rate for Payer: Kentucky WC Medicaid |
$12.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.69
|
| Rate for Payer: Ohio Health Group HMO |
$26.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.07
|
| Rate for Payer: PHCS Commercial |
$33.48
|
| Rate for Payer: United Healthcare All Payer |
$30.69
|
|
|
ENABLEX 15MG TABLET
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 33342027707
|
| Hospital Charge Code |
25000619
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.21
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
ENABLEX 15MG TABLET
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 33342027707
|
| Hospital Charge Code |
25000619
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.21
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
ENABLEX(DARIFEN HYDRO)7.5 MG T
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
NDC 69097043102
|
| Hospital Charge Code |
25000620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.02
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
ENABLEX(DARIFEN HYDRO)7.5 MG T
|
Facility
|
IP
|
$10.17
|
|
|
Service Code
|
NDC 69097043102
|
| Hospital Charge Code |
25000620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.02
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
ENBREL 25MG (50MG/ML) DISP SYR
|
Facility
|
OP
|
$3,789.40
|
|
|
Service Code
|
HCPCS J1438
|
| Hospital Charge Code |
25002056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,080.88 |
| Max. Negotiated Rate |
$3,637.82 |
| Rate for Payer: Aetna Commercial |
$2,917.84
|
| Rate for Payer: Anthem Medicaid |
$1,303.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,080.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,955.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,513.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,459.19
|
| Rate for Payer: Cash Price |
$1,894.70
|
| Rate for Payer: Cash Price |
$1,894.70
|
| Rate for Payer: Cigna Commercial |
$3,145.20
|
| Rate for Payer: First Health Commercial |
$3,599.93
|
| Rate for Payer: Humana Commercial |
$3,220.99
|
| Rate for Payer: Humana KY Medicaid |
$1,303.17
|
| Rate for Payer: Humana Medicare Advantage |
$1,080.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,316.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,107.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,796.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,297.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,329.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,334.67
|
| Rate for Payer: Ohio Health Group HMO |
$2,842.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,031.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,296.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,614.69
|
| Rate for Payer: PHCS Commercial |
$3,637.82
|
| Rate for Payer: United Healthcare All Payer |
$3,334.67
|
|
|
ENBREL 25MG (50MG/ML) DISP SYR
|
Facility
|
IP
|
$3,789.40
|
|
|
Service Code
|
HCPCS J1438
|
| Hospital Charge Code |
25002056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,136.82 |
| Max. Negotiated Rate |
$3,637.82 |
| Rate for Payer: Aetna Commercial |
$2,917.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,955.73
|
| Rate for Payer: Cash Price |
$1,894.70
|
| Rate for Payer: Cigna Commercial |
$3,145.20
|
| Rate for Payer: First Health Commercial |
$3,599.93
|
| Rate for Payer: Humana Commercial |
$3,220.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,107.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,796.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,136.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,334.67
|
| Rate for Payer: Ohio Health Group HMO |
$2,842.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,031.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,296.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,614.69
|
| Rate for Payer: PHCS Commercial |
$3,637.82
|
| Rate for Payer: United Healthcare All Payer |
$3,334.67
|
|
|
ENDCAP INPINGING NON STERILE
|
Facility
|
OP
|
$2,071.40
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$621.42 |
| Max. Negotiated Rate |
$1,988.54 |
| Rate for Payer: Aetna Commercial |
$1,594.98
|
| Rate for Payer: Anthem Medicaid |
$712.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,615.69
|
| Rate for Payer: Cash Price |
$1,035.70
|
| Rate for Payer: Cigna Commercial |
$1,719.26
|
| Rate for Payer: First Health Commercial |
$1,967.83
|
| Rate for Payer: Humana Commercial |
$1,760.69
|
| Rate for Payer: Humana KY Medicaid |
$712.35
|
| Rate for Payer: Kentucky WC Medicaid |
$719.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,698.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,528.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$621.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$726.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,822.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,553.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,657.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,802.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,429.27
|
| Rate for Payer: PHCS Commercial |
$1,988.54
|
| Rate for Payer: United Healthcare All Payer |
$1,822.83
|
|
|
ENDCAP INPINGING NON STERILE
|
Facility
|
IP
|
$2,071.40
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$621.42 |
| Max. Negotiated Rate |
$1,988.54 |
| Rate for Payer: Aetna Commercial |
$1,594.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,615.69
|
| Rate for Payer: Cash Price |
$1,035.70
|
| Rate for Payer: Cigna Commercial |
$1,719.26
|
| Rate for Payer: First Health Commercial |
$1,967.83
|
| Rate for Payer: Humana Commercial |
$1,760.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,698.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,528.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$621.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,822.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,553.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,657.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,802.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,429.27
|
| Rate for Payer: PHCS Commercial |
$1,988.54
|
| Rate for Payer: United Healthcare All Payer |
$1,822.83
|
|
|
END CAP LWR EXT T2 +0MM
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
END CAP LWR EXT T2 +0MM
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
ENDO-AVITENE 10MM SHEET
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
NDC 53276101015
|
| Hospital Charge Code |
27000238
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.00 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem Medicaid |
$127.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Humana KY Medicaid |
$127.24
|
| Rate for Payer: Kentucky WC Medicaid |
$128.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.30
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
ENDO-AVITENE 10MM SHEET
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
NDC 53276101015
|
| Hospital Charge Code |
27000238
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.00 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.30
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
