|
J TIP GW 1.5 260CM
|
Facility
|
IP
|
$822.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$246.60 |
| Max. Negotiated Rate |
$789.12 |
| Rate for Payer: Aetna Commercial |
$632.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$641.16
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$682.26
|
| Rate for Payer: First Health Commercial |
$780.90
|
| Rate for Payer: Humana Commercial |
$698.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$674.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$606.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$246.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$723.36
|
| Rate for Payer: Ohio Health Group HMO |
$616.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$657.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$567.18
|
| Rate for Payer: PHCS Commercial |
$789.12
|
| Rate for Payer: United Healthcare All Payer |
$723.36
|
|
|
J TIP GW 1.5 260CM
|
Facility
|
OP
|
$822.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$246.60 |
| Max. Negotiated Rate |
$789.12 |
| Rate for Payer: Aetna Commercial |
$632.94
|
| Rate for Payer: Anthem Medicaid |
$282.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$641.16
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$682.26
|
| Rate for Payer: First Health Commercial |
$780.90
|
| Rate for Payer: Humana Commercial |
$698.70
|
| Rate for Payer: Humana KY Medicaid |
$282.69
|
| Rate for Payer: Kentucky WC Medicaid |
$285.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$674.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$606.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$246.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$288.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$723.36
|
| Rate for Payer: Ohio Health Group HMO |
$616.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$657.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$567.18
|
| Rate for Payer: PHCS Commercial |
$789.12
|
| Rate for Payer: United Healthcare All Payer |
$723.36
|
|
|
JUGGERKNOT 2.9ANCHOR DBL LOAD
|
Facility
|
IP
|
$3,680.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,104.00 |
| Max. Negotiated Rate |
$3,532.80 |
| Rate for Payer: Aetna Commercial |
$2,833.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,870.40
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Cigna Commercial |
$3,054.40
|
| Rate for Payer: First Health Commercial |
$3,496.00
|
| Rate for Payer: Humana Commercial |
$3,128.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,017.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,715.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,104.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,238.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,760.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,201.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,539.20
|
| Rate for Payer: PHCS Commercial |
$3,532.80
|
| Rate for Payer: United Healthcare All Payer |
$3,238.40
|
|
|
JUGGERKNOT 2.9ANCHOR DBL LOAD
|
Facility
|
OP
|
$3,680.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,104.00 |
| Max. Negotiated Rate |
$3,532.80 |
| Rate for Payer: Aetna Commercial |
$2,833.60
|
| Rate for Payer: Anthem Medicaid |
$1,265.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,870.40
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Cigna Commercial |
$3,054.40
|
| Rate for Payer: First Health Commercial |
$3,496.00
|
| Rate for Payer: Humana Commercial |
$3,128.00
|
| Rate for Payer: Humana KY Medicaid |
$1,265.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,278.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,017.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,715.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,104.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,290.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,238.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,760.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,201.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,539.20
|
| Rate for Payer: PHCS Commercial |
$3,532.80
|
| Rate for Payer: United Healthcare All Payer |
$3,238.40
|
|
|
JUGGERKNOT 2.9 ANCHR DISP KIT
|
Facility
|
OP
|
$21,507.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,452.25 |
| Max. Negotiated Rate |
$20,647.20 |
| Rate for Payer: Aetna Commercial |
$16,560.78
|
| Rate for Payer: Anthem Medicaid |
$7,396.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,775.85
|
| Rate for Payer: Cash Price |
$10,753.75
|
| Rate for Payer: Cigna Commercial |
$17,851.22
|
| Rate for Payer: First Health Commercial |
$20,432.12
|
| Rate for Payer: Humana Commercial |
$18,281.38
|
| Rate for Payer: Humana KY Medicaid |
$7,396.43
|
| Rate for Payer: Kentucky WC Medicaid |
$7,471.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,636.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,872.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,452.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,544.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,926.60
|
| Rate for Payer: Ohio Health Group HMO |
$16,130.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,206.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,711.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,840.17
|
| Rate for Payer: PHCS Commercial |
$20,647.20
|
| Rate for Payer: United Healthcare All Payer |
$18,926.60
|
|
|
JUGGERKNOT 2.9 ANCHR DISP KIT
|
Facility
|
IP
|
$21,507.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,452.25 |
| Max. Negotiated Rate |
$20,647.20 |
| Rate for Payer: Aetna Commercial |
$16,560.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,775.85
|
| Rate for Payer: Cash Price |
$10,753.75
|
| Rate for Payer: Cigna Commercial |
$17,851.22
|
| Rate for Payer: First Health Commercial |
$20,432.12
|
| Rate for Payer: Humana Commercial |
$18,281.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,636.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,872.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,452.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,926.60
|
| Rate for Payer: Ohio Health Group HMO |
$16,130.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,206.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,711.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,840.17
|
| Rate for Payer: PHCS Commercial |
$20,647.20
|
| Rate for Payer: United Healthcare All Payer |
$18,926.60
|
|
|
JUGGERKNOT 2.9MM SFT ANCHR
|
Facility
|
IP
|
$3,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,113.00 |
| Max. Negotiated Rate |
$3,561.60 |
| Rate for Payer: Aetna Commercial |
$2,856.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,893.80
|
| Rate for Payer: Cash Price |
$1,855.00
|
| Rate for Payer: Cigna Commercial |
$3,079.30
|
| Rate for Payer: First Health Commercial |
$3,524.50
|
| Rate for Payer: Humana Commercial |
$3,153.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,042.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,737.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,113.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,264.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,782.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,227.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.90
|
| Rate for Payer: PHCS Commercial |
$3,561.60
|
| Rate for Payer: United Healthcare All Payer |
$3,264.80
|
|
|
JUGGERKNOT 2.9MM SFT ANCHR
|
Facility
|
OP
|
$3,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,113.00 |
| Max. Negotiated Rate |
$3,561.60 |
| Rate for Payer: Aetna Commercial |
$2,856.70
|
| Rate for Payer: Anthem Medicaid |
$1,275.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,893.80
|
| Rate for Payer: Cash Price |
$1,855.00
|
| Rate for Payer: Cigna Commercial |
$3,079.30
|
| Rate for Payer: First Health Commercial |
$3,524.50
|
| Rate for Payer: Humana Commercial |
$3,153.50
|
| Rate for Payer: Humana KY Medicaid |
$1,275.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1,288.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,042.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,737.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,113.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,301.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,264.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,782.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,227.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.90
|
| Rate for Payer: PHCS Commercial |
$3,561.60
|
| Rate for Payer: United Healthcare All Payer |
$3,264.80
|
|
|
JUNE KENTUCKY BLUE GRASS IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
JUNE KENTUCKY BLUE GRASS IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
JUVEDERM
|
Facility
|
IP
|
$1,293.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
76100110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.05 |
| 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 |
$1,073.61
|
| Rate for Payer: First Health Commercial |
$1,228.83
|
| Rate for Payer: Humana Commercial |
$1,099.47
|
| 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 |
$1,034.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,125.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.51
|
| 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 |
$183.59 |
| 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 |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cash Price |
$646.75
|
| Rate for Payer: Cigna Commercial |
$1,073.61
|
| Rate for Payer: First Health Commercial |
$1,228.83
|
| Rate for Payer: Humana Commercial |
$1,099.47
|
| Rate for Payer: Humana KY Medicaid |
$444.83
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| 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 |
$220.31
|
| 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 |
$1,034.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,125.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.51
|
| 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 |
$776.10 |
| Rate for Payer: Aetna Commercial |
$74.18
|
| Rate for Payer: Ambetter Exchange |
$49.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$49.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$49.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.17
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$49.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.31
|
| Rate for Payer: Multiplan PHCS |
$776.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$64.10
|
| Rate for Payer: UHCCP Medicaid |
$37.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$49.31
|
|
|
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 |
$300.00 |
| Rate for Payer: Aetna Commercial |
$74.18
|
| Rate for Payer: Ambetter Exchange |
$49.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$49.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$49.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.17
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$49.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.31
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$64.10
|
| Rate for Payer: UHCCP Medicaid |
$37.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$49.31
|
|
|
JUVEDERM(T
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
761T0110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| 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 |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| 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 |
$220.31
|
| 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 |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
JUVEDERM(T
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS 11950
|
| Hospital Charge Code |
761T0110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$238.05 |
| 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 |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| 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 |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
KADCYLA 160MG/8ML VIAL
|
Facility
|
IP
|
$34,789.53
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25003914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,436.86 |
| Max. Negotiated Rate |
$33,397.95 |
| Rate for Payer: Aetna Commercial |
$26,787.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,135.83
|
| Rate for Payer: Cash Price |
$17,394.76
|
| Rate for Payer: Cigna Commercial |
$28,875.31
|
| Rate for Payer: First Health Commercial |
$33,050.05
|
| Rate for Payer: Humana Commercial |
$29,571.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,527.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,674.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,436.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,614.79
|
| Rate for Payer: Ohio Health Group HMO |
$26,092.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,831.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30,266.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,004.78
|
| Rate for Payer: PHCS Commercial |
$33,397.95
|
| Rate for Payer: United Healthcare All Payer |
$30,614.79
|
|
|
KADCYLA 160MG/8ML VIAL
|
Facility
|
OP
|
$34,789.53
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25003914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.85 |
| Max. Negotiated Rate |
$33,397.95 |
| Rate for Payer: Aetna Commercial |
$26,787.94
|
| Rate for Payer: Anthem Medicaid |
$11,964.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,135.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$58.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.50
|
| Rate for Payer: Cash Price |
$17,394.76
|
| Rate for Payer: Cash Price |
$17,394.76
|
| Rate for Payer: Cigna Commercial |
$28,875.31
|
| Rate for Payer: First Health Commercial |
$33,050.05
|
| Rate for Payer: Humana Commercial |
$29,571.10
|
| Rate for Payer: Humana KY Medicaid |
$11,964.12
|
| Rate for Payer: Humana Medicare Advantage |
$41.85
|
| Rate for Payer: Kentucky WC Medicaid |
$12,085.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,527.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,674.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,204.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,614.79
|
| Rate for Payer: Ohio Health Group HMO |
$26,092.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,831.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30,266.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,004.78
|
| Rate for Payer: PHCS Commercial |
$33,397.95
|
| Rate for Payer: United Healthcare All Payer |
$30,614.79
|
|
|
KADCYLA 1MG (100MG VIAL)
|
Facility
|
IP
|
$21,743.48
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25002684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,523.04 |
| Max. Negotiated Rate |
$20,873.74 |
| Rate for Payer: Aetna Commercial |
$16,742.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,959.91
|
| Rate for Payer: Cash Price |
$10,871.74
|
| Rate for Payer: Cigna Commercial |
$18,047.09
|
| Rate for Payer: First Health Commercial |
$20,656.31
|
| Rate for Payer: Humana Commercial |
$18,481.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,829.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,046.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,523.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,134.26
|
| Rate for Payer: Ohio Health Group HMO |
$16,307.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,394.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,916.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,003.00
|
| Rate for Payer: PHCS Commercial |
$20,873.74
|
| Rate for Payer: United Healthcare All Payer |
$19,134.26
|
|
|
KADCYLA 1MG (100MG VIAL)
|
Facility
|
OP
|
$21,743.48
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
25002684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.85 |
| Max. Negotiated Rate |
$20,873.74 |
| Rate for Payer: Aetna Commercial |
$16,742.48
|
| Rate for Payer: Anthem Medicaid |
$7,477.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,959.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$58.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.50
|
| Rate for Payer: Cash Price |
$10,871.74
|
| Rate for Payer: Cash Price |
$10,871.74
|
| Rate for Payer: Cigna Commercial |
$18,047.09
|
| Rate for Payer: First Health Commercial |
$20,656.31
|
| Rate for Payer: Humana Commercial |
$18,481.96
|
| Rate for Payer: Humana KY Medicaid |
$7,477.58
|
| Rate for Payer: Humana Medicare Advantage |
$41.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,553.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,829.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,046.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,627.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,134.26
|
| Rate for Payer: Ohio Health Group HMO |
$16,307.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,394.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,916.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,003.00
|
| Rate for Payer: PHCS Commercial |
$20,873.74
|
| Rate for Payer: United Healthcare All Payer |
$19,134.26
|
|
|
KANJINTI 10mg (150MG SDV)
|
Facility
|
IP
|
$7,412.38
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,223.71 |
| 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 |
$5,929.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,448.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,114.54
|
| 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 |
$43.28 |
| 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 |
$43.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,781.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$60.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$58.43
|
| 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 |
$43.28
|
| 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 |
$51.94
|
| 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 |
$5,929.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,448.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,114.54
|
| Rate for Payer: PHCS Commercial |
$7,115.88
|
| Rate for Payer: United Healthcare All Payer |
$6,522.89
|
|
|
KANJINTI 10mg (from 420mg MDV)
|
Facility
|
IP
|
$494.15
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$148.25 |
| 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 |
$148.25
|
| 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 |
$395.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$429.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.96
|
| Rate for Payer: PHCS Commercial |
$474.38
|
| Rate for Payer: United Healthcare All Payer |
$434.85
|
|
|
KANJINTI 10mg (from 420mg MDV)
|
Facility
|
OP
|
$494.15
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
25004106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.28 |
| 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 |
$43.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$385.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$60.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$58.43
|
| 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 |
$43.28
|
| 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 |
$51.94
|
| 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 |
$395.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$429.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.96
|
| Rate for Payer: PHCS Commercial |
$474.38
|
| Rate for Payer: United Healthcare All Payer |
$434.85
|
|
|
KCENTRA 1U[500 unit vial]
|
Facility
|
OP
|
$6,090.92
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
25001809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$5,847.28 |
| Rate for Payer: Aetna Commercial |
$4,690.01
|
| Rate for Payer: Anthem Medicaid |
$2,094.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,750.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$2.89
|
| Rate for Payer: Cash Price |
$3,045.46
|
| Rate for Payer: Cash Price |
$3,045.46
|
| Rate for Payer: Cigna Commercial |
$5,055.46
|
| Rate for Payer: First Health Commercial |
$5,786.37
|
| Rate for Payer: Humana Commercial |
$5,177.28
|
| Rate for Payer: Humana KY Medicaid |
$2,094.67
|
| Rate for Payer: Humana Medicare Advantage |
$2.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,115.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,994.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,495.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,136.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,360.01
|
| Rate for Payer: Ohio Health Group HMO |
$4,568.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,872.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,299.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,202.73
|
| Rate for Payer: PHCS Commercial |
$5,847.28
|
| Rate for Payer: United Healthcare All Payer |
$5,360.01
|
|
