|
KELLER TIMMERMANS SHEATH 24.0
|
Facility
|
OP
|
$3,803.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$494.39 |
| Max. Negotiated Rate |
$3,650.88 |
| Rate for Payer: Aetna Commercial |
$2,928.31
|
| Rate for Payer: Anthem Medicaid |
$1,307.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,966.34
|
| Rate for Payer: Cash Price |
$1,901.50
|
| Rate for Payer: Cigna Commercial |
$3,156.49
|
| Rate for Payer: First Health Commercial |
$3,612.85
|
| Rate for Payer: Humana Commercial |
$3,232.55
|
| Rate for Payer: Humana KY Medicaid |
$1,307.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,321.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,118.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,806.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,334.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,346.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,852.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,178.93
|
| Rate for Payer: PHCS Commercial |
$3,650.88
|
| Rate for Payer: United Healthcare All Payer |
$3,346.64
|
|
|
KELLER TIMMERMANS SHEATH 24.0
|
Facility
|
IP
|
$3,803.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$494.39 |
| Max. Negotiated Rate |
$3,650.88 |
| Rate for Payer: Aetna Commercial |
$2,928.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,966.34
|
| Rate for Payer: Cash Price |
$1,901.50
|
| Rate for Payer: Cigna Commercial |
$3,156.49
|
| Rate for Payer: First Health Commercial |
$3,612.85
|
| Rate for Payer: Humana Commercial |
$3,232.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,118.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,806.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,346.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,852.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,178.93
|
| Rate for Payer: PHCS Commercial |
$3,650.88
|
| Rate for Payer: United Healthcare All Payer |
$3,346.64
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Facility
|
IP
|
$111.36
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
636T0064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$106.91 |
| Rate for Payer: Aetna Commercial |
$85.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.86
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Cigna Commercial |
$92.43
|
| Rate for Payer: First Health Commercial |
$105.79
|
| Rate for Payer: Humana Commercial |
$94.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.00
|
| Rate for Payer: Ohio Health Group HMO |
$83.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.52
|
| Rate for Payer: PHCS Commercial |
$106.91
|
| Rate for Payer: United Healthcare All Payer |
$98.00
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Facility
|
OP
|
$111.36
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
636T0064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$106.91 |
| Rate for Payer: Aetna Commercial |
$85.75
|
| Rate for Payer: Anthem Medicaid |
$38.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.86
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Cigna Commercial |
$92.43
|
| Rate for Payer: First Health Commercial |
$105.79
|
| Rate for Payer: Humana Commercial |
$94.66
|
| Rate for Payer: Humana KY Medicaid |
$38.30
|
| Rate for Payer: Kentucky WC Medicaid |
$38.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.00
|
| Rate for Payer: Ohio Health Group HMO |
$83.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.52
|
| Rate for Payer: PHCS Commercial |
$106.91
|
| Rate for Payer: United Healthcare All Payer |
$98.00
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Professional
|
Both
|
$111.36
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
25002400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.36
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Healthspan PPO |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.83
|
| Rate for Payer: Multiplan PHCS |
$66.82
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$77.95
|
| Rate for Payer: UHCCP Medicaid |
$38.98
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Facility
|
OP
|
$111.36
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$106.91 |
| Rate for Payer: Aetna Commercial |
$85.75
|
| Rate for Payer: Anthem Medicaid |
$38.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.86
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Cigna Commercial |
$92.43
|
| Rate for Payer: First Health Commercial |
$105.79
|
| Rate for Payer: Humana Commercial |
$94.66
|
| Rate for Payer: Humana KY Medicaid |
$38.30
|
| Rate for Payer: Kentucky WC Medicaid |
$38.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.00
|
| Rate for Payer: Ohio Health Group HMO |
$83.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.52
|
| Rate for Payer: PHCS Commercial |
$106.91
|
| Rate for Payer: United Healthcare All Payer |
$98.00
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Facility
|
IP
|
$115.89
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
25002400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$111.25 |
| Rate for Payer: Aetna Commercial |
$89.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.39
|
| Rate for Payer: Cash Price |
$57.94
|
| Rate for Payer: Cigna Commercial |
$96.19
|
| Rate for Payer: First Health Commercial |
$110.10
|
| Rate for Payer: Humana Commercial |
$98.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.98
|
| Rate for Payer: Ohio Health Group HMO |
$86.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.93
|
| Rate for Payer: PHCS Commercial |
$111.25
|
| Rate for Payer: United Healthcare All Payer |
$101.98
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Professional
|
Both
|
$111.36
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.36
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Healthspan PPO |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.83
|
| Rate for Payer: Multiplan PHCS |
$66.82
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$77.95
|
| Rate for Payer: UHCCP Medicaid |
$38.98
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Facility
|
IP
|
$111.36
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$106.91 |
| Rate for Payer: Aetna Commercial |
$85.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.86
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Cigna Commercial |
$92.43
|
| Rate for Payer: First Health Commercial |
$105.79
|
| Rate for Payer: Humana Commercial |
$94.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.00
|
| Rate for Payer: Ohio Health Group HMO |
$83.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.52
|
| Rate for Payer: PHCS Commercial |
$106.91
|
| Rate for Payer: United Healthcare All Payer |
$98.00
|
|
|
KENALOG 10 MG (40 MG VIAL)
|
Facility
|
OP
|
$115.89
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
25002400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$111.25 |
| Rate for Payer: Aetna Commercial |
$89.24
|
| Rate for Payer: Anthem Medicaid |
$39.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.39
|
| Rate for Payer: Cash Price |
$57.94
|
| Rate for Payer: Cigna Commercial |
$96.19
|
| Rate for Payer: First Health Commercial |
$110.10
|
| Rate for Payer: Humana Commercial |
$98.51
|
| Rate for Payer: Humana KY Medicaid |
$39.85
|
| Rate for Payer: Kentucky WC Medicaid |
$40.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.98
|
| Rate for Payer: Ohio Health Group HMO |
$86.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.93
|
| Rate for Payer: PHCS Commercial |
$111.25
|
| Rate for Payer: United Healthcare All Payer |
$101.98
|
|
|
KENALOG 10mg (from 400mg MDV)
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Healthspan PPO |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.83
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
|
|
KENALOG 10mg (from 400mg MDV)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 400mg MDV)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
636T0149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 400mg MDV)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
636T0149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 400mg MDV)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Facility
|
IP
|
$78.42
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
25004102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$75.28 |
| Rate for Payer: Aetna Commercial |
$60.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.17
|
| Rate for Payer: Cash Price |
$39.21
|
| Rate for Payer: Cigna Commercial |
$65.09
|
| Rate for Payer: First Health Commercial |
$74.50
|
| Rate for Payer: Humana Commercial |
$66.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.01
|
| Rate for Payer: Ohio Health Group HMO |
$58.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.31
|
| Rate for Payer: PHCS Commercial |
$75.28
|
| Rate for Payer: United Healthcare All Payer |
$69.01
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
636T0150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Facility
|
OP
|
$78.42
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
25004102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$75.28 |
| Rate for Payer: Aetna Commercial |
$60.38
|
| Rate for Payer: Anthem Medicaid |
$26.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.17
|
| Rate for Payer: Cash Price |
$39.21
|
| Rate for Payer: Cigna Commercial |
$65.09
|
| Rate for Payer: First Health Commercial |
$74.50
|
| Rate for Payer: Humana Commercial |
$66.66
|
| Rate for Payer: Humana KY Medicaid |
$26.97
|
| Rate for Payer: Kentucky WC Medicaid |
$27.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.01
|
| Rate for Payer: Ohio Health Group HMO |
$58.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.31
|
| Rate for Payer: PHCS Commercial |
$75.28
|
| Rate for Payer: United Healthcare All Payer |
$69.01
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Healthspan PPO |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.83
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
636T0150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG 10mg (from 50mg MDV)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
63600150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
KENALOG LUBRIDER 40MG/120MLLOT
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
NDC 3029305
|
| Hospital Charge Code |
25000816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.97
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
KENALOG LUBRIDER 40MG/120MLLOT
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
NDC 3029305
|
| Hospital Charge Code |
25000816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem Medicaid |
$29.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Humana KY Medicaid |
$29.92
|
| Rate for Payer: Kentucky WC Medicaid |
$30.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.97
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
KENALOG(TRIAMCINOLONE)IN O 5GM
|
Facility
|
OP
|
$9.98
|
|
|
Service Code
|
NDC 64980032005
|
| Hospital Charge Code |
25000817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$7.68
|
| Rate for Payer: Anthem Medicaid |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.78
|
| Rate for Payer: Cash Price |
$4.99
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: First Health Commercial |
$9.48
|
| Rate for Payer: Humana Commercial |
$8.48
|
| Rate for Payer: Humana KY Medicaid |
$3.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.78
|
| Rate for Payer: Ohio Health Group HMO |
$7.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.09
|
| Rate for Payer: PHCS Commercial |
$9.58
|
| Rate for Payer: United Healthcare All Payer |
$8.78
|
|
