|
SWIVELOCK 4.75*19.1 W/FIBERTAP
|
Facility
|
IP
|
$3,850.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.19 |
| Max. Negotiated Rate |
$3,696.60 |
| Rate for Payer: Aetna Commercial |
$2,964.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,003.48
|
| Rate for Payer: Cash Price |
$1,925.31
|
| Rate for Payer: Cigna Commercial |
$3,196.01
|
| Rate for Payer: First Health Commercial |
$3,658.09
|
| Rate for Payer: Humana Commercial |
$3,273.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,841.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,388.55
|
| Rate for Payer: Ohio Health Group HMO |
$2,887.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,080.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,350.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,656.93
|
| Rate for Payer: PHCS Commercial |
$3,696.60
|
| Rate for Payer: United Healthcare All Payer |
$3,388.55
|
|
|
SWIVELOCK 4.75*19.1 W/FIBERTAP
|
Facility
|
OP
|
$3,850.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.19 |
| Max. Negotiated Rate |
$3,696.60 |
| Rate for Payer: Aetna Commercial |
$2,964.98
|
| Rate for Payer: Anthem Medicaid |
$1,324.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,003.48
|
| Rate for Payer: Cash Price |
$1,925.31
|
| Rate for Payer: Cigna Commercial |
$3,196.01
|
| Rate for Payer: First Health Commercial |
$3,658.09
|
| Rate for Payer: Humana Commercial |
$3,273.03
|
| Rate for Payer: Humana KY Medicaid |
$1,324.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,337.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,841.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,388.55
|
| Rate for Payer: Ohio Health Group HMO |
$2,887.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,080.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,350.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,656.93
|
| Rate for Payer: PHCS Commercial |
$3,696.60
|
| Rate for Payer: United Healthcare All Payer |
$3,388.55
|
|
|
SWIVELOCK 4.75*24.5 SELF PUNCH
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
SWIVELOCK 4.75*24.5 SELF PUNCH
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
SWIVELOCK 5.5*19.1 W/ CLSD EYE
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
SWIVELOCK 5.5*19.1 W/ CLSD EYE
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
SWIVELOCK 5.5*24.5 SELF PUNCH
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
SWIVELOCK 5.5*24.5 SELF PUNCH
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
SWIVELOCK KNOTLESS
|
Facility
|
IP
|
$3,811.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,143.38 |
| Max. Negotiated Rate |
$3,658.80 |
| Rate for Payer: Aetna Commercial |
$2,934.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,972.78
|
| Rate for Payer: Cash Price |
$1,905.62
|
| Rate for Payer: Cigna Commercial |
$3,163.34
|
| Rate for Payer: First Health Commercial |
$3,620.69
|
| Rate for Payer: Humana Commercial |
$3,239.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,125.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,812.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,143.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,353.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,858.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,049.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,315.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,629.76
|
| Rate for Payer: PHCS Commercial |
$3,658.80
|
| Rate for Payer: United Healthcare All Payer |
$3,353.90
|
|
|
SWIVELOCK KNOTLESS
|
Facility
|
OP
|
$3,811.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,143.38 |
| Max. Negotiated Rate |
$3,658.80 |
| Rate for Payer: Aetna Commercial |
$2,934.66
|
| Rate for Payer: Anthem Medicaid |
$1,310.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,972.78
|
| Rate for Payer: Cash Price |
$1,905.62
|
| Rate for Payer: Cigna Commercial |
$3,163.34
|
| Rate for Payer: First Health Commercial |
$3,620.69
|
| Rate for Payer: Humana Commercial |
$3,239.56
|
| Rate for Payer: Humana KY Medicaid |
$1,310.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,324.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,125.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,812.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,143.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,336.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,353.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,858.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,049.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,315.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,629.76
|
| Rate for Payer: PHCS Commercial |
$3,658.80
|
| Rate for Payer: United Healthcare All Payer |
$3,353.90
|
|
|
SWIVLCK SELF PUNCH
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
SWIVLCK SELF PUNCH
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
SYMBICORT 160 4.5MCGINH 10.2GM
|
Facility
|
OP
|
$9.62
|
|
|
Service Code
|
NDC 186037028
|
| Hospital Charge Code |
25003506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.41
|
| Rate for Payer: Anthem Medicaid |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.50
|
| Rate for Payer: Cash Price |
$4.81
|
| Rate for Payer: Cigna Commercial |
$7.98
|
| Rate for Payer: First Health Commercial |
$9.14
|
| Rate for Payer: Humana Commercial |
$8.18
|
| Rate for Payer: Humana KY Medicaid |
$3.31
|
| Rate for Payer: Kentucky WC Medicaid |
$3.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.64
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
SYMBICORT 160 4.5MCGINH 10.2GM
|
Facility
|
IP
|
$9.62
|
|
|
Service Code
|
NDC 186037028
|
| Hospital Charge Code |
25003506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.50
|
| Rate for Payer: Cash Price |
$4.81
|
| Rate for Payer: Cigna Commercial |
$7.98
|
| Rate for Payer: First Health Commercial |
$9.14
|
| Rate for Payer: Humana Commercial |
$8.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.64
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
SYMBICORT 80/4.5mcg120PUFF INH
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
25004291
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
SYMBICORT 80/4.5mcg120PUFF INH
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
25004291
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
SYMBICORT 80 4.5MCG INHALER
|
Facility
|
OP
|
$9.27
|
|
|
Service Code
|
NDC 186037228
|
| Hospital Charge Code |
25001465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Anthem Medicaid |
$3.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.81
|
| Rate for Payer: Humana Commercial |
$7.88
|
| Rate for Payer: Humana KY Medicaid |
$3.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.16
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.40
|
| Rate for Payer: PHCS Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Payer |
$8.16
|
|
|
SYMBICORT 80 4.5MCG INHALER
|
Facility
|
IP
|
$9.27
|
|
|
Service Code
|
NDC 186037228
|
| Hospital Charge Code |
25001465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.81
|
| Rate for Payer: Humana Commercial |
$7.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.16
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.40
|
| Rate for Payer: PHCS Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Payer |
$8.16
|
|
|
SYMMETREL (AMANTADI 100MG/1CAP
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 50268006915
|
| Hospital Charge Code |
25001468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna Commercial |
$7.70
|
| Rate for Payer: Anthem Medicaid |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.80
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cigna Commercial |
$8.30
|
| Rate for Payer: First Health Commercial |
$9.50
|
| Rate for Payer: Humana Commercial |
$8.50
|
| Rate for Payer: Humana KY Medicaid |
$3.44
|
| Rate for Payer: Kentucky WC Medicaid |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.80
|
| Rate for Payer: Ohio Health Group HMO |
$7.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$9.60
|
| Rate for Payer: United Healthcare All Payer |
$8.80
|
|
|
SYMMETREL (AMANTADI 100MG/1CAP
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 50268006915
|
| Hospital Charge Code |
25001468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna Commercial |
$7.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.80
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cigna Commercial |
$8.30
|
| Rate for Payer: First Health Commercial |
$9.50
|
| Rate for Payer: Humana Commercial |
$8.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.80
|
| Rate for Payer: Ohio Health Group HMO |
$7.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$9.60
|
| Rate for Payer: United Healthcare All Payer |
$8.80
|
|
|
SYMMETRY 3*10*135
|
Facility
|
IP
|
$3,335.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$3,201.60 |
| Rate for Payer: Aetna Commercial |
$2,567.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,601.30
|
| Rate for Payer: Cash Price |
$1,667.50
|
| Rate for Payer: Cigna Commercial |
$2,768.05
|
| Rate for Payer: First Health Commercial |
$3,168.25
|
| Rate for Payer: Humana Commercial |
$2,834.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,501.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,301.15
|
| Rate for Payer: PHCS Commercial |
$3,201.60
|
| Rate for Payer: United Healthcare All Payer |
$2,934.80
|
|
|
SYMMETRY 3*10*135
|
Facility
|
OP
|
$3,335.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$3,201.60 |
| Rate for Payer: Aetna Commercial |
$2,567.95
|
| Rate for Payer: Anthem Medicaid |
$1,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,601.30
|
| Rate for Payer: Cash Price |
$1,667.50
|
| Rate for Payer: Cigna Commercial |
$2,768.05
|
| Rate for Payer: First Health Commercial |
$3,168.25
|
| Rate for Payer: Humana Commercial |
$2,834.75
|
| Rate for Payer: Humana KY Medicaid |
$1,146.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,158.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,169.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,501.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,301.15
|
| Rate for Payer: PHCS Commercial |
$3,201.60
|
| Rate for Payer: United Healthcare All Payer |
$2,934.80
|
|
|
SYMMETRY 3*2*135
|
Facility
|
OP
|
$3,335.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$3,201.60 |
| Rate for Payer: Aetna Commercial |
$2,567.95
|
| Rate for Payer: Anthem Medicaid |
$1,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,601.30
|
| Rate for Payer: Cash Price |
$1,667.50
|
| Rate for Payer: Cigna Commercial |
$2,768.05
|
| Rate for Payer: First Health Commercial |
$3,168.25
|
| Rate for Payer: Humana Commercial |
$2,834.75
|
| Rate for Payer: Humana KY Medicaid |
$1,146.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,158.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,169.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,501.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,301.15
|
| Rate for Payer: PHCS Commercial |
$3,201.60
|
| Rate for Payer: United Healthcare All Payer |
$2,934.80
|
|
|
SYMMETRY 3*2*135
|
Facility
|
IP
|
$3,335.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$3,201.60 |
| Rate for Payer: Aetna Commercial |
$2,567.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,601.30
|
| Rate for Payer: Cash Price |
$1,667.50
|
| Rate for Payer: Cigna Commercial |
$2,768.05
|
| Rate for Payer: First Health Commercial |
$3,168.25
|
| Rate for Payer: Humana Commercial |
$2,834.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,501.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,301.15
|
| Rate for Payer: PHCS Commercial |
$3,201.60
|
| Rate for Payer: United Healthcare All Payer |
$2,934.80
|
|
|
SYMMETRY 3*4*135
|
Facility
|
OP
|
$3,335.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$3,201.60 |
| Rate for Payer: Aetna Commercial |
$2,567.95
|
| Rate for Payer: Anthem Medicaid |
$1,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,601.30
|
| Rate for Payer: Cash Price |
$1,667.50
|
| Rate for Payer: Cigna Commercial |
$2,768.05
|
| Rate for Payer: First Health Commercial |
$3,168.25
|
| Rate for Payer: Humana Commercial |
$2,834.75
|
| Rate for Payer: Humana KY Medicaid |
$1,146.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,158.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,169.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,501.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,301.15
|
| Rate for Payer: PHCS Commercial |
$3,201.60
|
| Rate for Payer: United Healthcare All Payer |
$2,934.80
|
|
