|
TAKERU RX NC BALLOON 3.25*21
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TAKERU RX NC BALLOON 3.25*21
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TAKERU RX NC BALLOON 3.25*8
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 3.25*8
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 3.50*8
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 3.50*8
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 3.5*12
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 3.5*12
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 3.5*15
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 3.5*15
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 3.5*21
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 3.5*21
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 3*8
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 3*8
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 4*12
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 4*12
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 4*15
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 4*15
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 4*21
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 4*21
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU RX NC BALLOON 4*8
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU RX NC BALLOON 4*8
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAMBOCOR(FLECAINIDE) 50MG TAB
|
Facility
|
OP
|
$4.77
|
|
|
Service Code
|
NDC 54001020
|
| Hospital Charge Code |
25001484
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.96
|
| Rate for Payer: First Health Commercial |
$4.53
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.20
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.58
|
| Rate for Payer: United Healthcare All Payer |
$4.20
|
|
|
TAMBOCOR(FLECAINIDE) 50MG TAB
|
Facility
|
IP
|
$4.77
|
|
|
Service Code
|
NDC 54001020
|
| Hospital Charge Code |
25001484
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.96
|
| Rate for Payer: First Health Commercial |
$4.53
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.20
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.58
|
| Rate for Payer: United Healthcare All Payer |
$4.20
|
|
|
TAMIFLU 30MG/5ML RECON SUS 5ML
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
NDC 27241013909
|
| Hospital Charge Code |
25001486
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$8.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.19
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna Commercial |
$8.72
|
| Rate for Payer: First Health Commercial |
$9.98
|
| Rate for Payer: Humana Commercial |
$8.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$10.08
|
| Rate for Payer: United Healthcare All Payer |
$9.24
|
|
