|
J TIP GW 1.5 260CM
|
Facility
|
OP
|
$799.80
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.97 |
| Max. Negotiated Rate |
$767.81 |
| Rate for Payer: Aetna Commercial |
$615.85
|
| Rate for Payer: Anthem Medicaid |
$275.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$623.84
|
| Rate for Payer: Cash Price |
$399.90
|
| Rate for Payer: Cigna Commercial |
$663.83
|
| Rate for Payer: First Health Commercial |
$759.81
|
| Rate for Payer: Humana Commercial |
$679.83
|
| Rate for Payer: Humana KY Medicaid |
$275.05
|
| Rate for Payer: Kentucky WC Medicaid |
$277.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$655.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$703.82
|
| Rate for Payer: Ohio Health Group HMO |
$599.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.94
|
| Rate for Payer: PHCS Commercial |
$767.81
|
| Rate for Payer: United Healthcare All Payer |
$703.82
|
|
|
J TIP GW 1.5 260CM
|
Facility
|
IP
|
$799.80
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.97 |
| Max. Negotiated Rate |
$767.81 |
| Rate for Payer: Aetna Commercial |
$615.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$623.84
|
| Rate for Payer: Cash Price |
$399.90
|
| Rate for Payer: Cigna Commercial |
$663.83
|
| Rate for Payer: First Health Commercial |
$759.81
|
| Rate for Payer: Humana Commercial |
$679.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$655.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$703.82
|
| Rate for Payer: Ohio Health Group HMO |
$599.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.94
|
| Rate for Payer: PHCS Commercial |
$767.81
|
| Rate for Payer: United Healthcare All Payer |
$703.82
|
|
|
JUGGERKNOT 2.9ANCHOR DBL LOAD
|
Facility
|
IP
|
$3,768.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.84 |
| Max. Negotiated Rate |
$3,617.28 |
| Rate for Payer: Aetna Commercial |
$2,901.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,939.04
|
| Rate for Payer: Cash Price |
$1,884.00
|
| Rate for Payer: Cigna Commercial |
$3,127.44
|
| Rate for Payer: First Health Commercial |
$3,579.60
|
| Rate for Payer: Humana Commercial |
$3,202.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,089.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,780.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,130.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,315.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,826.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$753.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,168.08
|
| Rate for Payer: PHCS Commercial |
$3,617.28
|
| Rate for Payer: United Healthcare All Payer |
$3,315.84
|
|
|
JUGGERKNOT 2.9ANCHOR DBL LOAD
|
Facility
|
OP
|
$3,768.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.84 |
| Max. Negotiated Rate |
$3,617.28 |
| Rate for Payer: Aetna Commercial |
$2,901.36
|
| Rate for Payer: Anthem Medicaid |
$1,295.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,939.04
|
| Rate for Payer: Cash Price |
$1,884.00
|
| Rate for Payer: Cigna Commercial |
$3,127.44
|
| Rate for Payer: First Health Commercial |
$3,579.60
|
| Rate for Payer: Humana Commercial |
$3,202.80
|
| Rate for Payer: Humana KY Medicaid |
$1,295.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,309.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,089.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,780.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,130.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,321.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,315.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,826.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$753.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,168.08
|
| Rate for Payer: PHCS Commercial |
$3,617.28
|
| Rate for Payer: United Healthcare All Payer |
$3,315.84
|
|
|
JUGGERKNOT 2.9 ANCHR DISP KIT
|
Facility
|
OP
|
$20,867.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,712.75 |
| Max. Negotiated Rate |
$20,032.61 |
| Rate for Payer: Aetna Commercial |
$16,067.82
|
| Rate for Payer: Anthem Medicaid |
$7,176.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,276.49
|
| Rate for Payer: Cash Price |
$10,433.65
|
| Rate for Payer: Cigna Commercial |
$17,319.86
|
| Rate for Payer: First Health Commercial |
$19,823.94
|
| Rate for Payer: Humana Commercial |
$17,737.20
|
| Rate for Payer: Humana KY Medicaid |
$7,176.26
|
| Rate for Payer: Kentucky WC Medicaid |
$7,249.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,111.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,400.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,260.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,320.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,363.22
|
| Rate for Payer: Ohio Health Group HMO |
$15,650.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,173.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,712.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,468.86
|
| Rate for Payer: PHCS Commercial |
$20,032.61
|
| Rate for Payer: United Healthcare All Payer |
$18,363.22
|
|
|
JUGGERKNOT 2.9 ANCHR DISP KIT
|
Facility
|
IP
|
$20,867.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,712.75 |
| Max. Negotiated Rate |
$20,032.61 |
| Rate for Payer: Aetna Commercial |
$16,067.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,276.49
|
| Rate for Payer: Cash Price |
$10,433.65
|
| Rate for Payer: Cigna Commercial |
$17,319.86
|
| Rate for Payer: First Health Commercial |
$19,823.94
|
| Rate for Payer: Humana Commercial |
$17,737.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,111.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,400.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,260.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,363.22
|
| Rate for Payer: Ohio Health Group HMO |
$15,650.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,173.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,712.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,468.86
|
| Rate for Payer: PHCS Commercial |
$20,032.61
|
| Rate for Payer: United Healthcare All Payer |
$18,363.22
|
|
|
JUGGERKNOT 2.9MM SFT ANCHR
|
Facility
|
OP
|
$3,796.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$493.48 |
| Max. Negotiated Rate |
$3,644.16 |
| Rate for Payer: Aetna Commercial |
$2,922.92
|
| Rate for Payer: Anthem Medicaid |
$1,305.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,960.88
|
| Rate for Payer: Cash Price |
$1,898.00
|
| Rate for Payer: Cigna Commercial |
$3,150.68
|
| Rate for Payer: First Health Commercial |
$3,606.20
|
| Rate for Payer: Humana Commercial |
$3,226.60
|
| Rate for Payer: Humana KY Medicaid |
$1,305.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,318.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,112.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,801.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,138.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,331.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,340.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,847.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$759.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$493.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,176.76
|
| Rate for Payer: PHCS Commercial |
$3,644.16
|
| Rate for Payer: United Healthcare All Payer |
$3,340.48
|
|
|
JUGGERKNOT 2.9MM SFT ANCHR
|
Facility
|
IP
|
$3,796.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$493.48 |
| Max. Negotiated Rate |
$3,644.16 |
| Rate for Payer: Aetna Commercial |
$2,922.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,960.88
|
| Rate for Payer: Cash Price |
$1,898.00
|
| Rate for Payer: Cigna Commercial |
$3,150.68
|
| Rate for Payer: First Health Commercial |
$3,606.20
|
| Rate for Payer: Humana Commercial |
$3,226.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,112.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,801.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,138.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,340.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,847.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$759.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$493.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,176.76
|
| Rate for Payer: PHCS Commercial |
$3,644.16
|
| Rate for Payer: United Healthcare All Payer |
$3,340.48
|
|
|
JUNE KENTUCKY BLUE GRASS IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
JUNE KENTUCKY BLUE GRASS IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
JUVEDERM
|
Facility
|
IP
|
$1,293.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
76100110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$168.16 |
| Max. Negotiated Rate |
$1,241.76 |
| Rate for Payer: Aetna Commercial |
$996.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.93
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cigna Commercial |
$1,073.60
|
| Rate for Payer: First Health Commercial |
$1,228.82
|
| Rate for Payer: Humana Commercial |
$1,099.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$388.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,138.28
|
| Rate for Payer: Ohio Health Group HMO |
$970.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.98
|
| Rate for Payer: PHCS Commercial |
$1,241.76
|
| Rate for Payer: United Healthcare All Payer |
$1,138.28
|
|
|
JUVEDERM
|
Facility
|
OP
|
$1,293.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
76100110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$168.16 |
| Max. Negotiated Rate |
$1,241.76 |
| Rate for Payer: Aetna Commercial |
$996.00
|
| Rate for Payer: Anthem Medicaid |
$444.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cigna Commercial |
$1,073.60
|
| Rate for Payer: First Health Commercial |
$1,228.82
|
| Rate for Payer: Humana Commercial |
$1,099.48
|
| Rate for Payer: Humana KY Medicaid |
$444.83
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$449.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,138.28
|
| Rate for Payer: Ohio Health Group HMO |
$970.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.98
|
| Rate for Payer: PHCS Commercial |
$1,241.76
|
| Rate for Payer: United Healthcare All Payer |
$1,138.28
|
|
|
JUVEDERM
|
Professional
|
Both
|
$1,293.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
76100110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.16 |
| Max. Negotiated Rate |
$1,293.50 |
| Rate for Payer: Aetna Commercial |
$74.18
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,293.50
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cigna Commercial |
$107.27
|
| Rate for Payer: Healthspan PPO |
$84.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.79
|
| Rate for Payer: Multiplan PHCS |
$776.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$905.45
|
| Rate for Payer: UHCCP Medicaid |
$37.97
|
|
|
JUVEDERM(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
761P0110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.16 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$74.18
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$107.27
|
| Rate for Payer: Healthspan PPO |
$84.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.79
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$37.97
|
|
|
JUVEDERM(T
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
761T0110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.16 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.60
|
| Rate for Payer: First Health Commercial |
$753.82
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$158.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.98
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
JUVEDERM(T
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
761T0110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.16 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.60
|
| Rate for Payer: First Health Commercial |
$753.82
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$158.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.98
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
KADCYLA 160MG/8ML VIAL
|
Facility
|
OP
|
$34,275.38
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25003914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.37 |
| Max. Negotiated Rate |
$32,904.36 |
| Rate for Payer: Aetna Commercial |
$26,392.04
|
| Rate for Payer: Anthem Medicaid |
$11,787.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$38.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,734.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$53.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.80
|
| Rate for Payer: Cash Price |
$17,137.69
|
| Rate for Payer: Cash Price |
$17,137.69
|
| Rate for Payer: Cigna Commercial |
$28,448.57
|
| Rate for Payer: First Health Commercial |
$32,561.61
|
| Rate for Payer: Humana Commercial |
$29,134.07
|
| Rate for Payer: Humana KY Medicaid |
$11,787.30
|
| Rate for Payer: Humana Medicare Advantage |
$38.37
|
| Rate for Payer: Kentucky WC Medicaid |
$11,907.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,105.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,295.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,023.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,162.33
|
| Rate for Payer: Ohio Health Group HMO |
$25,706.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,855.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,455.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,625.37
|
| Rate for Payer: PHCS Commercial |
$32,904.36
|
| Rate for Payer: United Healthcare All Payer |
$30,162.33
|
|
|
KADCYLA 160MG/8ML VIAL
|
Facility
|
IP
|
$34,275.38
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25003914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,455.80 |
| Max. Negotiated Rate |
$32,904.36 |
| Rate for Payer: Aetna Commercial |
$26,392.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,734.80
|
| Rate for Payer: Cash Price |
$17,137.69
|
| Rate for Payer: Cigna Commercial |
$28,448.57
|
| Rate for Payer: First Health Commercial |
$32,561.61
|
| Rate for Payer: Humana Commercial |
$29,134.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,105.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,295.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,282.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,162.33
|
| Rate for Payer: Ohio Health Group HMO |
$25,706.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,855.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,455.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,625.37
|
| Rate for Payer: PHCS Commercial |
$32,904.36
|
| Rate for Payer: United Healthcare All Payer |
$30,162.33
|
|
|
KADCYLA 1MG (100MG VIAL)
|
Facility
|
IP
|
$21,422.15
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25002684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,784.88 |
| Max. Negotiated Rate |
$20,565.26 |
| Rate for Payer: Aetna Commercial |
$16,495.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,709.28
|
| Rate for Payer: Cash Price |
$10,711.08
|
| Rate for Payer: Cigna Commercial |
$17,780.38
|
| Rate for Payer: First Health Commercial |
$20,351.04
|
| Rate for Payer: Humana Commercial |
$18,208.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,566.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,809.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,426.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,851.49
|
| Rate for Payer: Ohio Health Group HMO |
$16,066.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,284.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,640.87
|
| Rate for Payer: PHCS Commercial |
$20,565.26
|
| Rate for Payer: United Healthcare All Payer |
$18,851.49
|
|
|
KADCYLA 1MG (100MG VIAL)
|
Facility
|
OP
|
$21,422.15
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25002684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.37 |
| Max. Negotiated Rate |
$20,565.26 |
| Rate for Payer: Aetna Commercial |
$16,495.06
|
| Rate for Payer: Anthem Medicaid |
$7,367.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$38.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,709.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$53.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.80
|
| Rate for Payer: Cash Price |
$10,711.08
|
| Rate for Payer: Cash Price |
$10,711.08
|
| Rate for Payer: Cigna Commercial |
$17,780.38
|
| Rate for Payer: First Health Commercial |
$20,351.04
|
| Rate for Payer: Humana Commercial |
$18,208.83
|
| Rate for Payer: Humana KY Medicaid |
$7,367.08
|
| Rate for Payer: Humana Medicare Advantage |
$38.37
|
| Rate for Payer: Kentucky WC Medicaid |
$7,442.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,566.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,809.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,514.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,851.49
|
| Rate for Payer: Ohio Health Group HMO |
$16,066.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,284.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,640.87
|
| Rate for Payer: PHCS Commercial |
$20,565.26
|
| Rate for Payer: United Healthcare All Payer |
$18,851.49
|
|
|
KANJINTI 10mg (150MG SDV)
|
Facility
|
IP
|
$7,412.38
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$963.61 |
| Max. Negotiated Rate |
$7,115.88 |
| Rate for Payer: Aetna Commercial |
$5,707.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,781.66
|
| Rate for Payer: Cash Price |
$3,706.19
|
| Rate for Payer: Cigna Commercial |
$6,152.28
|
| Rate for Payer: First Health Commercial |
$7,041.76
|
| Rate for Payer: Humana Commercial |
$6,300.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,078.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,470.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,223.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,522.89
|
| Rate for Payer: Ohio Health Group HMO |
$5,559.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,297.84
|
| Rate for Payer: PHCS Commercial |
$7,115.88
|
| Rate for Payer: United Healthcare All Payer |
$6,522.89
|
|
|
KANJINTI 10mg (150MG SDV)
|
Facility
|
OP
|
$7,412.38
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$7,115.88 |
| Rate for Payer: Aetna Commercial |
$5,707.53
|
| Rate for Payer: Anthem Medicaid |
$2,549.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,781.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.48
|
| Rate for Payer: Cash Price |
$3,706.19
|
| Rate for Payer: Cash Price |
$3,706.19
|
| Rate for Payer: Cigna Commercial |
$6,152.28
|
| Rate for Payer: First Health Commercial |
$7,041.76
|
| Rate for Payer: Humana Commercial |
$6,300.52
|
| Rate for Payer: Humana KY Medicaid |
$2,549.12
|
| Rate for Payer: Humana Medicare Advantage |
$12.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,078.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,470.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,522.89
|
| Rate for Payer: Ohio Health Group HMO |
$5,559.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,297.84
|
| Rate for Payer: PHCS Commercial |
$7,115.88
|
| Rate for Payer: United Healthcare All Payer |
$6,522.89
|
|
|
KANJINTI 10mg (from 420mg MDV)
|
Facility
|
OP
|
$494.15
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$474.38 |
| Rate for Payer: Aetna Commercial |
$380.50
|
| Rate for Payer: Anthem Medicaid |
$169.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$385.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.48
|
| Rate for Payer: Cash Price |
$247.07
|
| Rate for Payer: Cash Price |
$247.07
|
| Rate for Payer: Cigna Commercial |
$410.14
|
| Rate for Payer: First Health Commercial |
$469.44
|
| Rate for Payer: Humana Commercial |
$420.03
|
| Rate for Payer: Humana KY Medicaid |
$169.94
|
| Rate for Payer: Humana Medicare Advantage |
$12.21
|
| Rate for Payer: Kentucky WC Medicaid |
$171.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$364.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$173.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$434.85
|
| Rate for Payer: Ohio Health Group HMO |
$370.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.19
|
| Rate for Payer: PHCS Commercial |
$474.38
|
| Rate for Payer: United Healthcare All Payer |
$434.85
|
|
|
KANJINTI 10mg (from 420mg MDV)
|
Facility
|
IP
|
$494.15
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.24 |
| Max. Negotiated Rate |
$474.38 |
| Rate for Payer: Aetna Commercial |
$380.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$385.44
|
| Rate for Payer: Cash Price |
$247.07
|
| Rate for Payer: Cigna Commercial |
$410.14
|
| Rate for Payer: First Health Commercial |
$469.44
|
| Rate for Payer: Humana Commercial |
$420.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$364.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$434.85
|
| Rate for Payer: Ohio Health Group HMO |
$370.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.19
|
| Rate for Payer: PHCS Commercial |
$474.38
|
| Rate for Payer: United Healthcare All Payer |
$434.85
|
|
|
KCENTRA 1U[500 unit vial]
|
Facility
|
IP
|
$6,498.58
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
25001809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$844.82 |
| Max. Negotiated Rate |
$6,238.64 |
| Rate for Payer: Aetna Commercial |
$5,003.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,068.89
|
| Rate for Payer: Cash Price |
$3,249.29
|
| Rate for Payer: Cigna Commercial |
$5,393.82
|
| Rate for Payer: First Health Commercial |
$6,173.65
|
| Rate for Payer: Humana Commercial |
$5,523.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,328.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,795.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,949.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,718.75
|
| Rate for Payer: Ohio Health Group HMO |
$4,873.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,299.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$844.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,014.56
|
| Rate for Payer: PHCS Commercial |
$6,238.64
|
| Rate for Payer: United Healthcare All Payer |
$5,718.75
|
|
