|
SURGICEL 2 X 3 (OXIDIZED C 1EA
|
Facility
|
OP
|
$76.51
|
|
|
Service Code
|
NDC 63713001953
|
| Hospital Charge Code |
27000225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$73.45 |
| Rate for Payer: Aetna Commercial |
$58.91
|
| Rate for Payer: Anthem Medicaid |
$26.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.68
|
| Rate for Payer: Cash Price |
$38.26
|
| Rate for Payer: Cigna Commercial |
$63.50
|
| Rate for Payer: First Health Commercial |
$72.68
|
| Rate for Payer: Humana Commercial |
$65.03
|
| Rate for Payer: Humana KY Medicaid |
$26.31
|
| Rate for Payer: Kentucky WC Medicaid |
$26.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.33
|
| Rate for Payer: Ohio Health Group HMO |
$57.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.79
|
| Rate for Payer: PHCS Commercial |
$73.45
|
| Rate for Payer: United Healthcare All Payer |
$67.33
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
IP
|
$141.34
|
|
|
Service Code
|
NDC 63713001952
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$42.40 |
| Max. Negotiated Rate |
$135.69 |
| Rate for Payer: Aetna Commercial |
$108.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.25
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cigna Commercial |
$117.31
|
| Rate for Payer: First Health Commercial |
$134.27
|
| Rate for Payer: Humana Commercial |
$120.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.38
|
| Rate for Payer: Ohio Health Group HMO |
$106.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.52
|
| Rate for Payer: PHCS Commercial |
$135.69
|
| Rate for Payer: United Healthcare All Payer |
$124.38
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
OP
|
$141.34
|
|
|
Service Code
|
NDC 63713001952
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$42.40 |
| Max. Negotiated Rate |
$135.69 |
| Rate for Payer: Aetna Commercial |
$108.83
|
| Rate for Payer: Anthem Medicaid |
$48.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.25
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cigna Commercial |
$117.31
|
| Rate for Payer: First Health Commercial |
$134.27
|
| Rate for Payer: Humana Commercial |
$120.14
|
| Rate for Payer: Humana KY Medicaid |
$48.61
|
| Rate for Payer: Kentucky WC Medicaid |
$49.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.38
|
| Rate for Payer: Ohio Health Group HMO |
$106.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.52
|
| Rate for Payer: PHCS Commercial |
$135.69
|
| Rate for Payer: United Healthcare All Payer |
$124.38
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
OP
|
$121.57
|
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$36.47 |
| Max. Negotiated Rate |
$116.71 |
| Rate for Payer: Aetna Commercial |
$93.61
|
| Rate for Payer: Anthem Medicaid |
$41.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.82
|
| Rate for Payer: Cash Price |
$60.78
|
| Rate for Payer: Cigna Commercial |
$100.90
|
| Rate for Payer: First Health Commercial |
$115.49
|
| Rate for Payer: Humana Commercial |
$103.33
|
| Rate for Payer: Humana KY Medicaid |
$41.81
|
| Rate for Payer: Kentucky WC Medicaid |
$42.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.98
|
| Rate for Payer: Ohio Health Group HMO |
$91.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.88
|
| Rate for Payer: PHCS Commercial |
$116.71
|
| Rate for Payer: United Healthcare All Payer |
$106.98
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
IP
|
$121.57
|
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$36.47 |
| Max. Negotiated Rate |
$116.71 |
| Rate for Payer: Aetna Commercial |
$93.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.82
|
| Rate for Payer: Cash Price |
$60.78
|
| Rate for Payer: Cigna Commercial |
$100.90
|
| Rate for Payer: First Health Commercial |
$115.49
|
| Rate for Payer: Humana Commercial |
$103.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.98
|
| Rate for Payer: Ohio Health Group HMO |
$91.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.88
|
| Rate for Payer: PHCS Commercial |
$116.71
|
| Rate for Payer: United Healthcare All Payer |
$106.98
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
OP
|
$350.78
|
|
|
Service Code
|
NDC 30120180
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$105.23 |
| Max. Negotiated Rate |
$336.75 |
| Rate for Payer: Aetna Commercial |
$270.10
|
| Rate for Payer: Anthem Medicaid |
$120.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.61
|
| Rate for Payer: Cash Price |
$175.39
|
| Rate for Payer: Cigna Commercial |
$291.15
|
| Rate for Payer: First Health Commercial |
$333.24
|
| Rate for Payer: Humana Commercial |
$298.16
|
| Rate for Payer: Humana KY Medicaid |
$120.63
|
| Rate for Payer: Kentucky WC Medicaid |
$121.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.69
|
| Rate for Payer: Ohio Health Group HMO |
$263.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$305.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.04
|
| Rate for Payer: PHCS Commercial |
$336.75
|
| Rate for Payer: United Healthcare All Payer |
$308.69
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
IP
|
$350.78
|
|
|
Service Code
|
NDC 30120180
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$105.23 |
| Max. Negotiated Rate |
$336.75 |
| Rate for Payer: Aetna Commercial |
$270.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.61
|
| Rate for Payer: Cash Price |
$175.39
|
| Rate for Payer: Cigna Commercial |
$291.15
|
| Rate for Payer: First Health Commercial |
$333.24
|
| Rate for Payer: Humana Commercial |
$298.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.69
|
| Rate for Payer: Ohio Health Group HMO |
$263.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$305.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.04
|
| Rate for Payer: PHCS Commercial |
$336.75
|
| Rate for Payer: United Healthcare All Payer |
$308.69
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
OP
|
$316.22
|
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$94.87 |
| Max. Negotiated Rate |
$303.57 |
| Rate for Payer: Aetna Commercial |
$243.49
|
| Rate for Payer: Anthem Medicaid |
$108.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$246.65
|
| Rate for Payer: Cash Price |
$158.11
|
| Rate for Payer: Cigna Commercial |
$262.46
|
| Rate for Payer: First Health Commercial |
$300.41
|
| Rate for Payer: Humana Commercial |
$268.79
|
| Rate for Payer: Humana KY Medicaid |
$108.75
|
| Rate for Payer: Kentucky WC Medicaid |
$109.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$259.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$233.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$110.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$278.27
|
| Rate for Payer: Ohio Health Group HMO |
$237.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$275.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$218.19
|
| Rate for Payer: PHCS Commercial |
$303.57
|
| Rate for Payer: United Healthcare All Payer |
$278.27
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
IP
|
$316.22
|
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$94.87 |
| Max. Negotiated Rate |
$303.57 |
| Rate for Payer: Aetna Commercial |
$243.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$246.65
|
| Rate for Payer: Cash Price |
$158.11
|
| Rate for Payer: Cigna Commercial |
$262.46
|
| Rate for Payer: First Health Commercial |
$300.41
|
| Rate for Payer: Humana Commercial |
$268.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$259.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$233.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$278.27
|
| Rate for Payer: Ohio Health Group HMO |
$237.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$275.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$218.19
|
| Rate for Payer: PHCS Commercial |
$303.57
|
| Rate for Payer: United Healthcare All Payer |
$278.27
|
|
|
SURGICEL POWDER 3GM PKG
|
Professional
|
Both
|
$316.22
|
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$110.68 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Cash Price |
$158.11
|
| Rate for Payer: Multiplan PHCS |
$189.73
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$221.35
|
| Rate for Payer: UHCCP Medicaid |
$110.68
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
IP
|
$112.14
|
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.64 |
| Max. Negotiated Rate |
$107.65 |
| Rate for Payer: Aetna Commercial |
$86.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.47
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Cigna Commercial |
$93.08
|
| Rate for Payer: First Health Commercial |
$106.53
|
| Rate for Payer: Humana Commercial |
$95.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.68
|
| Rate for Payer: Ohio Health Group HMO |
$84.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.38
|
| Rate for Payer: PHCS Commercial |
$107.65
|
| Rate for Payer: United Healthcare All Payer |
$98.68
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
OP
|
$112.14
|
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.64 |
| Max. Negotiated Rate |
$107.65 |
| Rate for Payer: Aetna Commercial |
$86.35
|
| Rate for Payer: Anthem Medicaid |
$38.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.47
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Cigna Commercial |
$93.08
|
| Rate for Payer: First Health Commercial |
$106.53
|
| Rate for Payer: Humana Commercial |
$95.32
|
| Rate for Payer: Humana KY Medicaid |
$38.56
|
| Rate for Payer: Kentucky WC Medicaid |
$38.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.68
|
| Rate for Payer: Ohio Health Group HMO |
$84.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.38
|
| Rate for Payer: PHCS Commercial |
$107.65
|
| Rate for Payer: United Healthcare All Payer |
$98.68
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
OP
|
$125.27
|
|
|
Service Code
|
NDC 63713002081
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.58 |
| Max. Negotiated Rate |
$120.26 |
| Rate for Payer: Aetna Commercial |
$96.46
|
| Rate for Payer: Anthem Medicaid |
$43.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.71
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cigna Commercial |
$103.97
|
| Rate for Payer: First Health Commercial |
$119.01
|
| Rate for Payer: Humana Commercial |
$106.48
|
| Rate for Payer: Humana KY Medicaid |
$43.08
|
| Rate for Payer: Kentucky WC Medicaid |
$43.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.24
|
| Rate for Payer: Ohio Health Group HMO |
$93.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.44
|
| Rate for Payer: PHCS Commercial |
$120.26
|
| Rate for Payer: United Healthcare All Payer |
$110.24
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
IP
|
$125.27
|
|
|
Service Code
|
NDC 63713002081
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.58 |
| Max. Negotiated Rate |
$120.26 |
| Rate for Payer: Aetna Commercial |
$96.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.71
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cigna Commercial |
$103.97
|
| Rate for Payer: First Health Commercial |
$119.01
|
| Rate for Payer: Humana Commercial |
$106.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.24
|
| Rate for Payer: Ohio Health Group HMO |
$93.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.44
|
| Rate for Payer: PHCS Commercial |
$120.26
|
| Rate for Payer: United Healthcare All Payer |
$110.24
|
|
|
SURGICEL SNOW 1X2 INCH
|
Professional
|
Both
|
$112.14
|
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.25 |
| Max. Negotiated Rate |
$78.50 |
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Multiplan PHCS |
$67.28
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.50
|
| Rate for Payer: UHCCP Medicaid |
$39.25
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
IP
|
$158.17
|
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.45 |
| Max. Negotiated Rate |
$151.84 |
| Rate for Payer: Aetna Commercial |
$121.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.37
|
| Rate for Payer: Cash Price |
$79.08
|
| Rate for Payer: Cigna Commercial |
$131.28
|
| Rate for Payer: First Health Commercial |
$150.26
|
| Rate for Payer: Humana Commercial |
$134.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.19
|
| Rate for Payer: Ohio Health Group HMO |
$118.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.14
|
| Rate for Payer: PHCS Commercial |
$151.84
|
| Rate for Payer: United Healthcare All Payer |
$139.19
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
OP
|
$168.15
|
|
|
Service Code
|
NDC 63713002082
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.45 |
| Max. Negotiated Rate |
$161.42 |
| Rate for Payer: Aetna Commercial |
$129.48
|
| Rate for Payer: Anthem Medicaid |
$57.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.16
|
| Rate for Payer: Cash Price |
$84.08
|
| Rate for Payer: Cigna Commercial |
$139.56
|
| Rate for Payer: First Health Commercial |
$159.74
|
| Rate for Payer: Humana Commercial |
$142.93
|
| Rate for Payer: Humana KY Medicaid |
$57.83
|
| Rate for Payer: Kentucky WC Medicaid |
$58.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$147.97
|
| Rate for Payer: Ohio Health Group HMO |
$126.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$134.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.02
|
| Rate for Payer: PHCS Commercial |
$161.42
|
| Rate for Payer: United Healthcare All Payer |
$147.97
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
OP
|
$158.17
|
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.45 |
| Max. Negotiated Rate |
$151.84 |
| Rate for Payer: Aetna Commercial |
$121.79
|
| Rate for Payer: Anthem Medicaid |
$54.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.37
|
| Rate for Payer: Cash Price |
$79.08
|
| Rate for Payer: Cigna Commercial |
$131.28
|
| Rate for Payer: First Health Commercial |
$150.26
|
| Rate for Payer: Humana Commercial |
$134.44
|
| Rate for Payer: Humana KY Medicaid |
$54.39
|
| Rate for Payer: Kentucky WC Medicaid |
$54.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.19
|
| Rate for Payer: Ohio Health Group HMO |
$118.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.14
|
| Rate for Payer: PHCS Commercial |
$151.84
|
| Rate for Payer: United Healthcare All Payer |
$139.19
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
IP
|
$168.15
|
|
|
Service Code
|
NDC 63713002082
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.45 |
| Max. Negotiated Rate |
$161.42 |
| Rate for Payer: Aetna Commercial |
$129.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.16
|
| Rate for Payer: Cash Price |
$84.08
|
| Rate for Payer: Cigna Commercial |
$139.56
|
| Rate for Payer: First Health Commercial |
$159.74
|
| Rate for Payer: Humana Commercial |
$142.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$147.97
|
| Rate for Payer: Ohio Health Group HMO |
$126.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$134.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.02
|
| Rate for Payer: PHCS Commercial |
$161.42
|
| Rate for Payer: United Healthcare All Payer |
$147.97
|
|
|
SURGICEL SNOW 2X4 INCH
|
Professional
|
Both
|
$158.17
|
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.36 |
| Max. Negotiated Rate |
$110.72 |
| Rate for Payer: Cash Price |
$79.08
|
| Rate for Payer: Multiplan PHCS |
$94.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$110.72
|
| Rate for Payer: UHCCP Medicaid |
$55.36
|
|
|
SURGIFOAM 100CM 2 8 12.5CMSPNG
|
Facility
|
OP
|
$38.85
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
25003504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$37.30 |
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Anthem Medicaid |
$13.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.30
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: Cigna Commercial |
$32.25
|
| Rate for Payer: First Health Commercial |
$36.91
|
| Rate for Payer: Humana Commercial |
$33.02
|
| Rate for Payer: Humana KY Medicaid |
$13.36
|
| Rate for Payer: Kentucky WC Medicaid |
$13.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.19
|
| Rate for Payer: Ohio Health Group HMO |
$29.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.81
|
| Rate for Payer: PHCS Commercial |
$37.30
|
| Rate for Payer: United Healthcare All Payer |
$34.19
|
|
|
SURGIFOAM 100CM 2 8 12.5CMSPNG
|
Facility
|
IP
|
$38.85
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
25003504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$37.30 |
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.30
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: Cigna Commercial |
$32.25
|
| Rate for Payer: First Health Commercial |
$36.91
|
| Rate for Payer: Humana Commercial |
$33.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.19
|
| Rate for Payer: Ohio Health Group HMO |
$29.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.81
|
| Rate for Payer: PHCS Commercial |
$37.30
|
| Rate for Payer: United Healthcare All Payer |
$34.19
|
|
|
SURGIFOAM 50CM^2 8*6.25CM SPNG
|
Facility
|
OP
|
$30.96
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
25003747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$29.72 |
| Rate for Payer: Aetna Commercial |
$23.84
|
| Rate for Payer: Anthem Medicaid |
$10.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.15
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cigna Commercial |
$25.70
|
| Rate for Payer: First Health Commercial |
$29.41
|
| Rate for Payer: Humana Commercial |
$26.32
|
| Rate for Payer: Humana KY Medicaid |
$10.65
|
| Rate for Payer: Kentucky WC Medicaid |
$10.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.24
|
| Rate for Payer: Ohio Health Group HMO |
$23.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.36
|
| Rate for Payer: PHCS Commercial |
$29.72
|
| Rate for Payer: United Healthcare All Payer |
$27.24
|
|
|
SURGIFOAM 50CM^2 8*6.25CM SPNG
|
Facility
|
IP
|
$30.96
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
25003747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$29.72 |
| Rate for Payer: Aetna Commercial |
$23.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.15
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cigna Commercial |
$25.70
|
| Rate for Payer: First Health Commercial |
$29.41
|
| Rate for Payer: Humana Commercial |
$26.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.24
|
| Rate for Payer: Ohio Health Group HMO |
$23.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.36
|
| Rate for Payer: PHCS Commercial |
$29.72
|
| Rate for Payer: United Healthcare All Payer |
$27.24
|
|
|
SURGIMEND COLLAGEN MATRIX 25*4
|
Facility
|
OP
|
$94,100.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28,230.00 |
| Max. Negotiated Rate |
$90,336.00 |
| Rate for Payer: Aetna Commercial |
$72,457.00
|
| Rate for Payer: Anthem Medicaid |
$32,360.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73,398.00
|
| Rate for Payer: Cash Price |
$47,050.00
|
| Rate for Payer: Cigna Commercial |
$78,103.00
|
| Rate for Payer: First Health Commercial |
$89,395.00
|
| Rate for Payer: Humana Commercial |
$79,985.00
|
| Rate for Payer: Humana KY Medicaid |
$32,360.99
|
| Rate for Payer: Kentucky WC Medicaid |
$32,690.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77,162.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69,445.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,230.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$33,010.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82,808.00
|
| Rate for Payer: Ohio Health Group HMO |
$70,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81,867.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64,929.00
|
| Rate for Payer: PHCS Commercial |
$90,336.00
|
| Rate for Payer: United Healthcare All Payer |
$82,808.00
|
|
