|
FLAT&UPRIGHABD COMP AP & ERECT
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
320T0118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem Medicaid |
$121.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Humana KY Medicaid |
$121.74
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$122.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
320P0118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.82 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Ambetter Exchange |
$33.45
|
| Rate for Payer: Anthem Medicaid |
$25.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$33.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$40.14
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Humana Medicaid |
$25.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$33.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.65
|
| Rate for Payer: Molina Healthcare Passport |
$25.15
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$43.48
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$33.45
|
|
|
FLEBOGAMMA 500mg(10gm) SDV
|
Facility
|
OP
|
$5,770.46
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$5,539.64 |
| Rate for Payer: Aetna Commercial |
$4,443.25
|
| Rate for Payer: Anthem Medicaid |
$1,984.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$55.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,500.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.28
|
| Rate for Payer: Cash Price |
$2,885.23
|
| Rate for Payer: Cash Price |
$2,885.23
|
| Rate for Payer: Cigna Commercial |
$4,789.48
|
| Rate for Payer: First Health Commercial |
$5,481.94
|
| Rate for Payer: Humana Commercial |
$4,904.89
|
| Rate for Payer: Humana KY Medicaid |
$1,984.46
|
| Rate for Payer: Humana Medicare Advantage |
$55.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,004.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,731.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,258.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,024.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,078.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,327.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,616.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,020.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,981.62
|
| Rate for Payer: PHCS Commercial |
$5,539.64
|
| Rate for Payer: United Healthcare All Payer |
$5,078.00
|
|
|
FLEBOGAMMA 500mg(10gm) SDV
|
Facility
|
IP
|
$5,770.46
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,731.14 |
| Max. Negotiated Rate |
$5,539.64 |
| Rate for Payer: Aetna Commercial |
$4,443.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,500.96
|
| Rate for Payer: Cash Price |
$2,885.23
|
| Rate for Payer: Cigna Commercial |
$4,789.48
|
| Rate for Payer: First Health Commercial |
$5,481.94
|
| Rate for Payer: Humana Commercial |
$4,904.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,731.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,258.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,731.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,078.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,327.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,616.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,020.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,981.62
|
| Rate for Payer: PHCS Commercial |
$5,539.64
|
| Rate for Payer: United Healthcare All Payer |
$5,078.00
|
|
|
FLEBOGAMMA 500mg(20gm) SDV
|
Facility
|
OP
|
$11,540.92
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$11,079.28 |
| Rate for Payer: Aetna Commercial |
$8,886.51
|
| Rate for Payer: Anthem Medicaid |
$3,968.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$55.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,001.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.28
|
| Rate for Payer: Cash Price |
$5,770.46
|
| Rate for Payer: Cash Price |
$5,770.46
|
| Rate for Payer: Cigna Commercial |
$9,578.96
|
| Rate for Payer: First Health Commercial |
$10,963.87
|
| Rate for Payer: Humana Commercial |
$9,809.78
|
| Rate for Payer: Humana KY Medicaid |
$3,968.92
|
| Rate for Payer: Humana Medicare Advantage |
$55.76
|
| Rate for Payer: Kentucky WC Medicaid |
$4,009.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,463.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,517.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,048.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,156.01
|
| Rate for Payer: Ohio Health Group HMO |
$8,655.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,232.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,040.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,963.23
|
| Rate for Payer: PHCS Commercial |
$11,079.28
|
| Rate for Payer: United Healthcare All Payer |
$10,156.01
|
|
|
FLEBOGAMMA 500mg(20gm) SDV
|
Facility
|
IP
|
$11,540.92
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,462.28 |
| Max. Negotiated Rate |
$11,079.28 |
| Rate for Payer: Aetna Commercial |
$8,886.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,001.92
|
| Rate for Payer: Cash Price |
$5,770.46
|
| Rate for Payer: Cigna Commercial |
$9,578.96
|
| Rate for Payer: First Health Commercial |
$10,963.87
|
| Rate for Payer: Humana Commercial |
$9,809.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,463.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,517.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,462.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,156.01
|
| Rate for Payer: Ohio Health Group HMO |
$8,655.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,232.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,040.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,963.23
|
| Rate for Payer: PHCS Commercial |
$11,079.28
|
| Rate for Payer: United Healthcare All Payer |
$10,156.01
|
|
|
FLEBOGAMMA 500mg(2.5gm) SDV
|
Facility
|
IP
|
$1,442.62
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$432.79 |
| Max. Negotiated Rate |
$1,384.92 |
| Rate for Payer: Aetna Commercial |
$1,110.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,125.24
|
| Rate for Payer: Cash Price |
$721.31
|
| Rate for Payer: Cigna Commercial |
$1,197.37
|
| Rate for Payer: First Health Commercial |
$1,370.49
|
| Rate for Payer: Humana Commercial |
$1,226.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,182.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,064.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$432.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,269.51
|
| Rate for Payer: Ohio Health Group HMO |
$1,081.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,154.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,255.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$995.41
|
| Rate for Payer: PHCS Commercial |
$1,384.92
|
| Rate for Payer: United Healthcare All Payer |
$1,269.51
|
|
|
FLEBOGAMMA 500mg(2.5gm) SDV
|
Facility
|
OP
|
$1,442.62
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$1,384.92 |
| Rate for Payer: Aetna Commercial |
$1,110.82
|
| Rate for Payer: Anthem Medicaid |
$496.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$55.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,125.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.28
|
| Rate for Payer: Cash Price |
$721.31
|
| Rate for Payer: Cash Price |
$721.31
|
| Rate for Payer: Cigna Commercial |
$1,197.37
|
| Rate for Payer: First Health Commercial |
$1,370.49
|
| Rate for Payer: Humana Commercial |
$1,226.23
|
| Rate for Payer: Humana KY Medicaid |
$496.12
|
| Rate for Payer: Humana Medicare Advantage |
$55.76
|
| Rate for Payer: Kentucky WC Medicaid |
$501.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,182.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,064.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$506.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,269.51
|
| Rate for Payer: Ohio Health Group HMO |
$1,081.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,154.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,255.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$995.41
|
| Rate for Payer: PHCS Commercial |
$1,384.92
|
| Rate for Payer: United Healthcare All Payer |
$1,269.51
|
|
|
FLEBOGAMMA 500mg(5gm) SDV
|
Facility
|
IP
|
$2,885.23
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$865.57 |
| Max. Negotiated Rate |
$2,769.82 |
| Rate for Payer: Aetna Commercial |
$2,221.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,250.48
|
| Rate for Payer: Cash Price |
$1,442.62
|
| Rate for Payer: Cigna Commercial |
$2,394.74
|
| Rate for Payer: First Health Commercial |
$2,740.97
|
| Rate for Payer: Humana Commercial |
$2,452.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,365.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,129.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$865.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,539.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,163.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,308.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,510.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,990.81
|
| Rate for Payer: PHCS Commercial |
$2,769.82
|
| Rate for Payer: United Healthcare All Payer |
$2,539.00
|
|
|
FLEBOGAMMA 500mg(5gm) SDV
|
Facility
|
OP
|
$2,885.23
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$2,769.82 |
| Rate for Payer: Aetna Commercial |
$2,221.63
|
| Rate for Payer: Anthem Medicaid |
$992.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$55.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,250.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.28
|
| Rate for Payer: Cash Price |
$1,442.62
|
| Rate for Payer: Cash Price |
$1,442.62
|
| Rate for Payer: Cigna Commercial |
$2,394.74
|
| Rate for Payer: First Health Commercial |
$2,740.97
|
| Rate for Payer: Humana Commercial |
$2,452.45
|
| Rate for Payer: Humana KY Medicaid |
$992.23
|
| Rate for Payer: Humana Medicare Advantage |
$55.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1,002.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,365.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,129.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,012.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,539.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,163.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,308.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,510.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,990.81
|
| Rate for Payer: PHCS Commercial |
$2,769.82
|
| Rate for Payer: United Healthcare All Payer |
$2,539.00
|
|
|
FLEETS PHOSPHO-SODA 1.5 1.5OZ
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 132020140
|
| Hospital Charge Code |
25000680
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
FLEETS PHOSPHO-SODA 1.5 1.5OZ
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 132020140
|
| Hospital Charge Code |
25000680
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
FLEXBAND ANCHOR W DRIVER
|
Facility
|
IP
|
$3,755.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.50 |
| Max. Negotiated Rate |
$3,604.80 |
| Rate for Payer: Aetna Commercial |
$2,891.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,928.90
|
| Rate for Payer: Cash Price |
$1,877.50
|
| Rate for Payer: Cigna Commercial |
$3,116.65
|
| Rate for Payer: First Health Commercial |
$3,567.25
|
| Rate for Payer: Humana Commercial |
$3,191.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,079.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,771.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,126.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,304.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,816.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,266.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,590.95
|
| Rate for Payer: PHCS Commercial |
$3,604.80
|
| Rate for Payer: United Healthcare All Payer |
$3,304.40
|
|
|
FLEXBAND ANCHOR W DRIVER
|
Facility
|
OP
|
$3,755.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.50 |
| Max. Negotiated Rate |
$3,604.80 |
| Rate for Payer: Aetna Commercial |
$2,891.35
|
| Rate for Payer: Anthem Medicaid |
$1,291.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,928.90
|
| Rate for Payer: Cash Price |
$1,877.50
|
| Rate for Payer: Cigna Commercial |
$3,116.65
|
| Rate for Payer: First Health Commercial |
$3,567.25
|
| Rate for Payer: Humana Commercial |
$3,191.75
|
| Rate for Payer: Humana KY Medicaid |
$1,291.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,304.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,079.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,771.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,126.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,317.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,304.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,816.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,266.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,590.95
|
| Rate for Payer: PHCS Commercial |
$3,604.80
|
| Rate for Payer: United Healthcare All Payer |
$3,304.40
|
|
|
FLEXBAND DYNAMIC MAT 0.5*16CM
|
Facility
|
IP
|
$13,170.45
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,951.14 |
| Max. Negotiated Rate |
$12,643.63 |
| Rate for Payer: Aetna Commercial |
$10,141.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,272.95
|
| Rate for Payer: Cash Price |
$6,585.23
|
| Rate for Payer: Cigna Commercial |
$10,931.47
|
| Rate for Payer: First Health Commercial |
$12,511.93
|
| Rate for Payer: Humana Commercial |
$11,194.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,799.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,719.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,951.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,590.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,877.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,536.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,458.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,087.61
|
| Rate for Payer: PHCS Commercial |
$12,643.63
|
| Rate for Payer: United Healthcare All Payer |
$11,590.00
|
|
|
FLEXBAND DYNAMIC MAT 0.5*16CM
|
Facility
|
OP
|
$13,170.45
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,951.14 |
| Max. Negotiated Rate |
$12,643.63 |
| Rate for Payer: Aetna Commercial |
$10,141.25
|
| Rate for Payer: Anthem Medicaid |
$4,529.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,272.95
|
| Rate for Payer: Cash Price |
$6,585.23
|
| Rate for Payer: Cigna Commercial |
$10,931.47
|
| Rate for Payer: First Health Commercial |
$12,511.93
|
| Rate for Payer: Humana Commercial |
$11,194.88
|
| Rate for Payer: Humana KY Medicaid |
$4,529.32
|
| Rate for Payer: Kentucky WC Medicaid |
$4,575.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,799.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,719.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,951.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,620.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,590.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,877.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,536.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,458.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,087.61
|
| Rate for Payer: PHCS Commercial |
$12,643.63
|
| Rate for Payer: United Healthcare All Payer |
$11,590.00
|
|
|
FLEXBAND MULTI KIT
|
Facility
|
OP
|
$18,537.70
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,561.31 |
| Max. Negotiated Rate |
$17,796.19 |
| Rate for Payer: Aetna Commercial |
$14,274.03
|
| Rate for Payer: Anthem Medicaid |
$6,375.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,459.41
|
| Rate for Payer: Cash Price |
$9,268.85
|
| Rate for Payer: Cigna Commercial |
$15,386.29
|
| Rate for Payer: First Health Commercial |
$17,610.81
|
| Rate for Payer: Humana Commercial |
$15,757.05
|
| Rate for Payer: Humana KY Medicaid |
$6,375.12
|
| Rate for Payer: Kentucky WC Medicaid |
$6,440.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,200.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,680.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,561.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,503.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,313.18
|
| Rate for Payer: Ohio Health Group HMO |
$13,903.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,830.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,127.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,791.01
|
| Rate for Payer: PHCS Commercial |
$17,796.19
|
| Rate for Payer: United Healthcare All Payer |
$16,313.18
|
|
|
FLEXBAND MULTI KIT
|
Facility
|
IP
|
$18,537.70
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,561.31 |
| Max. Negotiated Rate |
$17,796.19 |
| Rate for Payer: Aetna Commercial |
$14,274.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,459.41
|
| Rate for Payer: Cash Price |
$9,268.85
|
| Rate for Payer: Cigna Commercial |
$15,386.29
|
| Rate for Payer: First Health Commercial |
$17,610.81
|
| Rate for Payer: Humana Commercial |
$15,757.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,200.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,680.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,561.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,313.18
|
| Rate for Payer: Ohio Health Group HMO |
$13,903.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,830.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,127.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,791.01
|
| Rate for Payer: PHCS Commercial |
$17,796.19
|
| Rate for Payer: United Healthcare All Payer |
$16,313.18
|
|
|
FLEXBAND SOLO KIT
|
Facility
|
OP
|
$16,965.20
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,089.56 |
| Max. Negotiated Rate |
$16,286.59 |
| Rate for Payer: Aetna Commercial |
$13,063.20
|
| Rate for Payer: Anthem Medicaid |
$5,834.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,232.86
|
| Rate for Payer: Cash Price |
$8,482.60
|
| Rate for Payer: Cigna Commercial |
$14,081.12
|
| Rate for Payer: First Health Commercial |
$16,116.94
|
| Rate for Payer: Humana Commercial |
$14,420.42
|
| Rate for Payer: Humana KY Medicaid |
$5,834.33
|
| Rate for Payer: Kentucky WC Medicaid |
$5,893.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,911.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,520.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,089.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,951.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,929.38
|
| Rate for Payer: Ohio Health Group HMO |
$12,723.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,572.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,759.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,705.99
|
| Rate for Payer: PHCS Commercial |
$16,286.59
|
| Rate for Payer: United Healthcare All Payer |
$14,929.38
|
|
|
FLEXBAND SOLO KIT
|
Facility
|
IP
|
$16,965.20
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,089.56 |
| Max. Negotiated Rate |
$16,286.59 |
| Rate for Payer: Aetna Commercial |
$13,063.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,232.86
|
| Rate for Payer: Cash Price |
$8,482.60
|
| Rate for Payer: Cigna Commercial |
$14,081.12
|
| Rate for Payer: First Health Commercial |
$16,116.94
|
| Rate for Payer: Humana Commercial |
$14,420.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,911.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,520.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,089.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,929.38
|
| Rate for Payer: Ohio Health Group HMO |
$12,723.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,572.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,759.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,705.99
|
| Rate for Payer: PHCS Commercial |
$16,286.59
|
| Rate for Payer: United Healthcare All Payer |
$14,929.38
|
|
|
FLEXERIL 5 MG TABLET
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 52817033010
|
| Hospital Charge Code |
25000681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
FLEXERIL 5 MG TABLET
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 52817033010
|
| Hospital Charge Code |
25000681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
FLEXERIL(CYCLOBENZAP 10MG/1TAB
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
25000682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
FLEXERIL(CYCLOBENZAP 10MG/1TAB
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
25000682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
FLEX& EXT BEND VIEWS ONLY LUM
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
32000055
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$423.36 |
| Rate for Payer: Aetna Commercial |
$339.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.98
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$366.03
|
| Rate for Payer: First Health Commercial |
$418.95
|
| Rate for Payer: Humana Commercial |
$374.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$361.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$325.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.08
|
| Rate for Payer: Ohio Health Group HMO |
$330.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.29
|
| Rate for Payer: PHCS Commercial |
$423.36
|
| Rate for Payer: United Healthcare All Payer |
$388.08
|
|
