|
TM TIBIAL CONE MEDIUM 36*31
|
Facility
|
IP
|
$21,893.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.21 |
| Max. Negotiated Rate |
$21,018.14 |
| Rate for Payer: Aetna Commercial |
$16,858.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,077.24
|
| Rate for Payer: Cash Price |
$10,946.95
|
| Rate for Payer: Cigna Commercial |
$18,171.94
|
| Rate for Payer: First Health Commercial |
$20,799.20
|
| Rate for Payer: Humana Commercial |
$18,609.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,953.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,568.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,266.63
|
| Rate for Payer: Ohio Health Group HMO |
$16,420.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,787.11
|
| Rate for Payer: PHCS Commercial |
$21,018.14
|
| Rate for Payer: United Healthcare All Payer |
$19,266.63
|
|
|
TM TIBIAL CONE MEDIUM 41*34
|
Facility
|
OP
|
$21,893.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.21 |
| Max. Negotiated Rate |
$21,018.14 |
| Rate for Payer: Aetna Commercial |
$16,858.30
|
| Rate for Payer: Anthem Medicaid |
$7,529.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,077.24
|
| Rate for Payer: Cash Price |
$10,946.95
|
| Rate for Payer: Cigna Commercial |
$18,171.94
|
| Rate for Payer: First Health Commercial |
$20,799.20
|
| Rate for Payer: Humana Commercial |
$18,609.82
|
| Rate for Payer: Humana KY Medicaid |
$7,529.31
|
| Rate for Payer: Kentucky WC Medicaid |
$7,605.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,953.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,568.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,680.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,266.63
|
| Rate for Payer: Ohio Health Group HMO |
$16,420.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,787.11
|
| Rate for Payer: PHCS Commercial |
$21,018.14
|
| Rate for Payer: United Healthcare All Payer |
$19,266.63
|
|
|
TM TIBIAL CONE MEDIUM 41*34
|
Facility
|
IP
|
$21,893.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.21 |
| Max. Negotiated Rate |
$21,018.14 |
| Rate for Payer: Aetna Commercial |
$16,858.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,077.24
|
| Rate for Payer: Cash Price |
$10,946.95
|
| Rate for Payer: Cigna Commercial |
$18,171.94
|
| Rate for Payer: First Health Commercial |
$20,799.20
|
| Rate for Payer: Humana Commercial |
$18,609.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,953.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,568.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,266.63
|
| Rate for Payer: Ohio Health Group HMO |
$16,420.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,787.11
|
| Rate for Payer: PHCS Commercial |
$21,018.14
|
| Rate for Payer: United Healthcare All Payer |
$19,266.63
|
|
|
TM TIBIAL CONE MEDIUM 46*34
|
Facility
|
IP
|
$21,893.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.21 |
| Max. Negotiated Rate |
$21,018.14 |
| Rate for Payer: Aetna Commercial |
$16,858.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,077.24
|
| Rate for Payer: Cash Price |
$10,946.95
|
| Rate for Payer: Cigna Commercial |
$18,171.94
|
| Rate for Payer: First Health Commercial |
$20,799.20
|
| Rate for Payer: Humana Commercial |
$18,609.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,953.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,568.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,266.63
|
| Rate for Payer: Ohio Health Group HMO |
$16,420.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,787.11
|
| Rate for Payer: PHCS Commercial |
$21,018.14
|
| Rate for Payer: United Healthcare All Payer |
$19,266.63
|
|
|
TM TIBIAL CONE MEDIUM 46*34
|
Facility
|
OP
|
$21,893.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.21 |
| Max. Negotiated Rate |
$21,018.14 |
| Rate for Payer: Aetna Commercial |
$16,858.30
|
| Rate for Payer: Anthem Medicaid |
$7,529.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,077.24
|
| Rate for Payer: Cash Price |
$10,946.95
|
| Rate for Payer: Cigna Commercial |
$18,171.94
|
| Rate for Payer: First Health Commercial |
$20,799.20
|
| Rate for Payer: Humana Commercial |
$18,609.82
|
| Rate for Payer: Humana KY Medicaid |
$7,529.31
|
| Rate for Payer: Kentucky WC Medicaid |
$7,605.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,953.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,568.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,680.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,266.63
|
| Rate for Payer: Ohio Health Group HMO |
$16,420.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,787.11
|
| Rate for Payer: PHCS Commercial |
$21,018.14
|
| Rate for Payer: United Healthcare All Payer |
$19,266.63
|
|
|
TNTMY HMSTRNG KNEE/HIPMULTTNDN
|
Facility
|
IP
|
$770.00
|
|
|
Service Code
|
HCPCS 27391
|
| Hospital Charge Code |
76100833
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$739.20 |
| Rate for Payer: Aetna Commercial |
$592.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$600.60
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$639.10
|
| Rate for Payer: First Health Commercial |
$731.50
|
| Rate for Payer: Humana Commercial |
$654.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$631.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$568.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$231.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$677.60
|
| Rate for Payer: Ohio Health Group HMO |
$577.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.70
|
| Rate for Payer: PHCS Commercial |
$739.20
|
| Rate for Payer: United Healthcare All Payer |
$677.60
|
|
|
TNTMY HMSTRNG KNEE/HIPMULTTNDN
|
Facility
|
OP
|
$770.00
|
|
|
Service Code
|
HCPCS 27391
|
| Hospital Charge Code |
76100833
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$592.90
|
| Rate for Payer: Anthem Medicaid |
$264.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$600.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$639.10
|
| Rate for Payer: First Health Commercial |
$731.50
|
| Rate for Payer: Humana Commercial |
$654.50
|
| Rate for Payer: Humana KY Medicaid |
$264.80
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$267.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$631.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$568.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$270.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$677.60
|
| Rate for Payer: Ohio Health Group HMO |
$577.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.70
|
| Rate for Payer: PHCS Commercial |
$739.20
|
| Rate for Payer: United Healthcare All Payer |
$677.60
|
|
|
TNTMY HMSTRNG KNEE/HIPMULTTNDN
|
Professional
|
Both
|
$770.00
|
|
|
Service Code
|
HCPCS 27391
|
| Hospital Charge Code |
761P0833
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$269.50 |
| Max. Negotiated Rate |
$915.28 |
| Rate for Payer: Aetna Commercial |
$831.50
|
| Rate for Payer: Anthem Medicaid |
$362.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$770.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$915.28
|
| Rate for Payer: Healthspan PPO |
$753.16
|
| Rate for Payer: Humana Medicaid |
$362.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$708.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$370.23
|
| Rate for Payer: Molina Healthcare Passport |
$362.97
|
| Rate for Payer: Multiplan PHCS |
$462.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$539.00
|
| Rate for Payer: UHCCP Medicaid |
$269.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$366.60
|
|
|
TNTMY HMSTRNG KNEE/HIPMULTTNDN
|
Professional
|
Both
|
$770.00
|
|
|
Service Code
|
HCPCS 27391
|
| Hospital Charge Code |
76100833
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$269.50 |
| Max. Negotiated Rate |
$915.28 |
| Rate for Payer: Aetna Commercial |
$831.50
|
| Rate for Payer: Anthem Medicaid |
$362.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$770.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$915.28
|
| Rate for Payer: Healthspan PPO |
$753.16
|
| Rate for Payer: Humana Medicaid |
$362.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$708.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$370.23
|
| Rate for Payer: Molina Healthcare Passport |
$362.97
|
| Rate for Payer: Multiplan PHCS |
$462.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$539.00
|
| Rate for Payer: UHCCP Medicaid |
$269.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$366.60
|
|
|
TOBI(TOBRAMYCIN SOLN)300MG/5ML
|
Facility
|
IP
|
$28.75
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
25002520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$22.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.42
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cigna Commercial |
$23.86
|
| Rate for Payer: First Health Commercial |
$27.31
|
| Rate for Payer: Humana Commercial |
$24.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.30
|
| Rate for Payer: Ohio Health Group HMO |
$21.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.91
|
| Rate for Payer: PHCS Commercial |
$27.60
|
| Rate for Payer: United Healthcare All Payer |
$25.30
|
|
|
TOBI(TOBRAMYCIN SOLN)300MG/5ML
|
Facility
|
OP
|
$28.75
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
25002520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$22.14
|
| Rate for Payer: Anthem Medicaid |
$9.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.42
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cigna Commercial |
$23.86
|
| Rate for Payer: First Health Commercial |
$27.31
|
| Rate for Payer: Humana Commercial |
$24.44
|
| Rate for Payer: Humana KY Medicaid |
$9.89
|
| Rate for Payer: Kentucky WC Medicaid |
$9.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.30
|
| Rate for Payer: Ohio Health Group HMO |
$21.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.91
|
| Rate for Payer: PHCS Commercial |
$27.60
|
| Rate for Payer: United Healthcare All Payer |
$25.30
|
|
|
TOBRADEX EYE DROPS 2.5 ML
|
Facility
|
OP
|
$3.78
|
|
|
Service Code
|
NDC 574403125
|
| Hospital Charge Code |
25003526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Anthem Medicaid |
$1.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna Commercial |
$3.14
|
| Rate for Payer: First Health Commercial |
$3.59
|
| Rate for Payer: Humana Commercial |
$3.21
|
| Rate for Payer: Humana KY Medicaid |
$1.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.33
|
| Rate for Payer: Ohio Health Group HMO |
$2.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.17
|
| Rate for Payer: PHCS Commercial |
$3.63
|
| Rate for Payer: United Healthcare All Payer |
$3.33
|
|
|
TOBRADEX EYE DROPS 2.5 ML
|
Facility
|
IP
|
$3.78
|
|
|
Service Code
|
NDC 574403125
|
| Hospital Charge Code |
25003526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna Commercial |
$3.14
|
| Rate for Payer: First Health Commercial |
$3.59
|
| Rate for Payer: Humana Commercial |
$3.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.33
|
| Rate for Payer: Ohio Health Group HMO |
$2.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.17
|
| Rate for Payer: PHCS Commercial |
$3.63
|
| Rate for Payer: United Healthcare All Payer |
$3.33
|
|
|
TOBRAMYCIN (PEAK)
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS 80200
|
| Hospital Charge Code |
30000050
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem Medicaid |
$33.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.13
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Humana KY Medicaid |
$33.70
|
| Rate for Payer: Humana Medicare Advantage |
$16.13
|
| Rate for Payer: Kentucky WC Medicaid |
$34.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.38
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
TOBRAMYCIN (PEAK)
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS 80200
|
| Hospital Charge Code |
30000050
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.38
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
TOBREX (TOBRAMYCIN).3% O 3.5GM
|
Facility
|
IP
|
$28.66
|
|
|
Service Code
|
NDC 78081301
|
| Hospital Charge Code |
25001557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$27.51 |
| Rate for Payer: Aetna Commercial |
$22.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.35
|
| Rate for Payer: Cash Price |
$14.33
|
| Rate for Payer: Cigna Commercial |
$23.79
|
| Rate for Payer: First Health Commercial |
$27.23
|
| Rate for Payer: Humana Commercial |
$24.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.22
|
| Rate for Payer: Ohio Health Group HMO |
$21.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.88
|
| Rate for Payer: PHCS Commercial |
$27.51
|
| Rate for Payer: United Healthcare All Payer |
$25.22
|
|
|
TOBREX (TOBRAMYCIN).3% O 3.5GM
|
Facility
|
OP
|
$28.66
|
|
|
Service Code
|
NDC 78081301
|
| Hospital Charge Code |
25001557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$27.51 |
| Rate for Payer: Aetna Commercial |
$22.07
|
| Rate for Payer: Anthem Medicaid |
$9.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.35
|
| Rate for Payer: Cash Price |
$14.33
|
| Rate for Payer: Cigna Commercial |
$23.79
|
| Rate for Payer: First Health Commercial |
$27.23
|
| Rate for Payer: Humana Commercial |
$24.36
|
| Rate for Payer: Humana KY Medicaid |
$9.86
|
| Rate for Payer: Kentucky WC Medicaid |
$9.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.22
|
| Rate for Payer: Ohio Health Group HMO |
$21.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.88
|
| Rate for Payer: PHCS Commercial |
$27.51
|
| Rate for Payer: United Healthcare All Payer |
$25.22
|
|
|
TOBREX (TOBRAMYCIN).3% OPH 5ML
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
25001558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna Commercial |
$0.45
|
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.49
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.56
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Humana Commercial |
$0.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.44
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.18
|
| Rate for Payer: PHCS Commercial |
$0.57
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
TOBREX (TOBRAMYCIN).3% OPH 5ML
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
25001558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna Commercial |
$0.45
|
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem Medicaid |
$0.20
|
| Rate for Payer: Anthem Medicaid |
$0.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: Cigna Commercial |
$0.49
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.56
|
| Rate for Payer: Humana Commercial |
$0.50
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Humana KY Medicaid |
$0.20
|
| Rate for Payer: Humana KY Medicaid |
$0.28
|
| Rate for Payer: Kentucky WC Medicaid |
$0.28
|
| Rate for Payer: Kentucky WC Medicaid |
$0.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.44
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.25
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: PHCS Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
| Rate for Payer: United Healthcare All Payer |
$0.52
|
|
|
TOFRANIL 10MG TAB
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 69584042510
|
| Hospital Charge Code |
25001560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
TOFRANIL 10MG TAB
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 69584042510
|
| Hospital Charge Code |
25001560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
TOFRANIL (IMIPRAMINE 25MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 69315013401
|
| Hospital Charge Code |
25001559
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
TOFRANIL (IMIPRAMINE 25MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 69315013401
|
| Hospital Charge Code |
25001559
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
TONSIL & ADENOID UNDER 12
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
76101706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$209.24 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$423.91
|
| Rate for Payer: Anthem Medicaid |
$209.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$421.16
|
| Rate for Payer: Healthspan PPO |
$357.49
|
| Rate for Payer: Humana Medicaid |
$209.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$376.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.42
|
| Rate for Payer: Molina Healthcare Passport |
$209.24
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.33
|
|
|
TONSIL & ADENOID UNDER 12
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
76101706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Humana KY Medicaid |
$240.73
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$243.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$245.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
