|
TRACHEOBRONC W/FIBERSCOPE(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 31725
|
| Hospital Charge Code |
410P0061
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$98.98 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$159.57
|
| Rate for Payer: Anthem Medicaid |
$98.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$145.88
|
| Rate for Payer: Healthspan PPO |
$124.59
|
| Rate for Payer: Humana Medicaid |
$98.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$100.96
|
| Rate for Payer: Molina Healthcare Passport |
$98.98
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$99.97
|
|
|
TRACHEOSTOMY
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 31603
|
| Hospital Charge Code |
41000029
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$251.27 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$372.33
|
| Rate for Payer: Anthem Medicaid |
$251.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$339.79
|
| Rate for Payer: Healthspan PPO |
$290.71
|
| Rate for Payer: Humana Medicaid |
$251.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$293.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$256.30
|
| Rate for Payer: Molina Healthcare Passport |
$251.27
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$253.78
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC
|
Facility
|
IP
|
$46,850.15
|
|
|
Service Code
|
MSDRG 012
|
| Min. Negotiated Rate |
$31,791.17 |
| Max. Negotiated Rate |
$46,850.15 |
| Rate for Payer: Anthem Medicaid |
$31,791.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$33,464.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$46,850.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$45,176.93
|
| Rate for Payer: Humana KY Medicaid |
$31,791.17
|
| Rate for Payer: Humana Medicare Advantage |
$33,464.39
|
| Rate for Payer: Kentucky WC Medicaid |
$32,109.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40,157.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$32,426.99
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC
|
Facility
|
IP
|
$60,319.45
|
|
|
Service Code
|
MSDRG 011
|
| Min. Negotiated Rate |
$40,931.05 |
| Max. Negotiated Rate |
$60,319.45 |
| Rate for Payer: Anthem Medicaid |
$40,931.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$43,085.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$60,319.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$58,165.18
|
| Rate for Payer: Humana KY Medicaid |
$40,931.05
|
| Rate for Payer: Humana Medicare Advantage |
$43,085.32
|
| Rate for Payer: Kentucky WC Medicaid |
$41,340.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51,702.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$41,749.68
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$31,417.89
|
|
|
Service Code
|
MSDRG 013
|
| Min. Negotiated Rate |
$21,319.28 |
| Max. Negotiated Rate |
$31,417.89 |
| Rate for Payer: Anthem Medicaid |
$21,319.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22,441.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31,417.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$30,295.82
|
| Rate for Payer: Humana KY Medicaid |
$21,319.28
|
| Rate for Payer: Humana Medicare Advantage |
$22,441.35
|
| Rate for Payer: Kentucky WC Medicaid |
$21,532.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26,929.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$21,745.67
|
|
|
TRACHEOSTOMY(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 31603
|
| Hospital Charge Code |
410P0029
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$251.27 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$372.33
|
| Rate for Payer: Anthem Medicaid |
$251.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$339.79
|
| Rate for Payer: Healthspan PPO |
$290.71
|
| Rate for Payer: Humana Medicaid |
$251.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$293.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$256.30
|
| Rate for Payer: Molina Healthcare Passport |
$251.27
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$253.78
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$171,963.60
|
|
|
Service Code
|
MSDRG 004
|
| Min. Negotiated Rate |
$116,689.58 |
| Max. Negotiated Rate |
$171,963.60 |
| Rate for Payer: Anthem Medicaid |
$116,689.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$122,831.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$171,963.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$165,822.04
|
| Rate for Payer: Humana KY Medicaid |
$116,689.58
|
| Rate for Payer: Humana Medicare Advantage |
$122,831.14
|
| Rate for Payer: Kentucky WC Medicaid |
$117,856.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147,397.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$119,023.37
|
|
|
TRACHEOTOMY
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 31600
|
| Hospital Charge Code |
41000028
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$230.38 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$660.05
|
| Rate for Payer: Anthem Medicaid |
$230.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$604.18
|
| Rate for Payer: Healthspan PPO |
$515.35
|
| Rate for Payer: Humana Medicaid |
$230.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$521.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$234.99
|
| Rate for Payer: Molina Healthcare Passport |
$230.38
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$232.68
|
|
|
TRACHEOTOMY(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 31600
|
| Hospital Charge Code |
410P0028
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$230.38 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$660.05
|
| Rate for Payer: Anthem Medicaid |
$230.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$604.18
|
| Rate for Payer: Healthspan PPO |
$515.35
|
| Rate for Payer: Humana Medicaid |
$230.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$521.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$234.99
|
| Rate for Payer: Molina Healthcare Passport |
$230.38
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$232.68
|
|
|
TRACHOMY, FENESTR PX WSKI FLAP
|
Professional
|
Both
|
$1,552.00
|
|
|
Service Code
|
HCPCS 31610
|
| Hospital Charge Code |
410P0030
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$432.19 |
| Max. Negotiated Rate |
$1,552.00 |
| Rate for Payer: Aetna Commercial |
$1,099.04
|
| Rate for Payer: Anthem Medicaid |
$432.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,552.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,004.48
|
| Rate for Payer: Healthspan PPO |
$858.10
|
| Rate for Payer: Humana Medicaid |
$432.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$908.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$931.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,086.40
|
| Rate for Payer: UHCCP Medicaid |
$543.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
|
|
TRACHOMY, FENESTR PX WSKI FLAP
|
Professional
|
Both
|
$1,552.00
|
|
|
Service Code
|
HCPCS 31610
|
| Hospital Charge Code |
41000030
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$432.19 |
| Max. Negotiated Rate |
$1,552.00 |
| Rate for Payer: Aetna Commercial |
$1,099.04
|
| Rate for Payer: Anthem Medicaid |
$432.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,552.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,004.48
|
| Rate for Payer: Healthspan PPO |
$858.10
|
| Rate for Payer: Humana Medicaid |
$432.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$908.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$931.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,086.40
|
| Rate for Payer: UHCCP Medicaid |
$543.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
|
|
TRACH PERC KIT BLUE RHINO SZ 6
|
Facility
|
OP
|
$3,915.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$508.95 |
| Max. Negotiated Rate |
$3,758.40 |
| Rate for Payer: Aetna Commercial |
$3,014.55
|
| Rate for Payer: Anthem Medicaid |
$1,346.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,053.70
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cigna Commercial |
$3,249.45
|
| Rate for Payer: First Health Commercial |
$3,719.25
|
| Rate for Payer: Humana Commercial |
$3,327.75
|
| Rate for Payer: Humana KY Medicaid |
$1,346.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,360.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,210.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,889.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,174.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,373.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,445.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,936.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,213.65
|
| Rate for Payer: PHCS Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare All Payer |
$3,445.20
|
|
|
TRACH PERC KIT BLUE RHINO SZ 6
|
Facility
|
IP
|
$3,915.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$508.95 |
| Max. Negotiated Rate |
$3,758.40 |
| Rate for Payer: Aetna Commercial |
$3,014.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,053.70
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cigna Commercial |
$3,249.45
|
| Rate for Payer: First Health Commercial |
$3,719.25
|
| Rate for Payer: Humana Commercial |
$3,327.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,210.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,889.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,174.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,445.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,936.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,213.65
|
| Rate for Payer: PHCS Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare All Payer |
$3,445.20
|
|
|
TRACH PERC KIT BLUE RHINO SZ 8
|
Facility
|
IP
|
$3,915.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$508.95 |
| Max. Negotiated Rate |
$3,758.40 |
| Rate for Payer: Aetna Commercial |
$3,014.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,053.70
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cigna Commercial |
$3,249.45
|
| Rate for Payer: First Health Commercial |
$3,719.25
|
| Rate for Payer: Humana Commercial |
$3,327.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,210.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,889.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,174.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,445.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,936.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,213.65
|
| Rate for Payer: PHCS Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare All Payer |
$3,445.20
|
|
|
TRACH PERC KIT BLUE RHINO SZ 8
|
Facility
|
OP
|
$3,915.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$508.95 |
| Max. Negotiated Rate |
$3,758.40 |
| Rate for Payer: Aetna Commercial |
$3,014.55
|
| Rate for Payer: Anthem Medicaid |
$1,346.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,053.70
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cigna Commercial |
$3,249.45
|
| Rate for Payer: First Health Commercial |
$3,719.25
|
| Rate for Payer: Humana Commercial |
$3,327.75
|
| Rate for Payer: Humana KY Medicaid |
$1,346.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,360.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,210.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,889.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,174.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,373.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,445.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,936.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,213.65
|
| Rate for Payer: PHCS Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare All Payer |
$3,445.20
|
|
|
TRACRIUM (ATRACURIU 100MG/10ML
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
NDC 71288070211
|
| Hospital Charge Code |
25003530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.13
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
TRACRIUM (ATRACURIU 100MG/10ML
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
NDC 71288070211
|
| Hospital Charge Code |
25003530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$42.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$42.30
|
| Rate for Payer: Kentucky WC Medicaid |
$42.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.13
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
TRADJENTA 5MG TABLET
|
Facility
|
OP
|
$34.50
|
|
|
Service Code
|
NDC 597014061
|
| Hospital Charge Code |
25003531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$26.56
|
| Rate for Payer: Anthem Medicaid |
$11.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.91
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Cigna Commercial |
$28.64
|
| Rate for Payer: First Health Commercial |
$32.78
|
| Rate for Payer: Humana Commercial |
$29.32
|
| Rate for Payer: Humana KY Medicaid |
$11.86
|
| Rate for Payer: Kentucky WC Medicaid |
$11.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.36
|
| Rate for Payer: Ohio Health Group HMO |
$25.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.70
|
| Rate for Payer: PHCS Commercial |
$33.12
|
| Rate for Payer: United Healthcare All Payer |
$30.36
|
|
|
TRADJENTA 5MG TABLET
|
Facility
|
IP
|
$34.50
|
|
|
Service Code
|
NDC 597014061
|
| Hospital Charge Code |
25003531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$26.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.91
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Cigna Commercial |
$28.64
|
| Rate for Payer: First Health Commercial |
$32.78
|
| Rate for Payer: Humana Commercial |
$29.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.36
|
| Rate for Payer: Ohio Health Group HMO |
$25.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.70
|
| Rate for Payer: PHCS Commercial |
$33.12
|
| Rate for Payer: United Healthcare All Payer |
$30.36
|
|
|
TRAILBLAZER 0.014
|
Facility
|
IP
|
$1,735.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.55 |
| Max. Negotiated Rate |
$1,665.60 |
| Rate for Payer: Aetna Commercial |
$1,335.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,353.30
|
| Rate for Payer: Cash Price |
$867.50
|
| Rate for Payer: Cigna Commercial |
$1,440.05
|
| Rate for Payer: First Health Commercial |
$1,648.25
|
| Rate for Payer: Humana Commercial |
$1,474.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,422.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,280.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$520.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,526.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$225.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$537.85
|
| Rate for Payer: PHCS Commercial |
$1,665.60
|
| Rate for Payer: United Healthcare All Payer |
$1,526.80
|
|
|
TRAILBLAZER 0.014
|
Facility
|
OP
|
$1,735.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.55 |
| Max. Negotiated Rate |
$1,665.60 |
| Rate for Payer: Aetna Commercial |
$1,335.95
|
| Rate for Payer: Anthem Medicaid |
$596.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,353.30
|
| Rate for Payer: Cash Price |
$867.50
|
| Rate for Payer: Cigna Commercial |
$1,440.05
|
| Rate for Payer: First Health Commercial |
$1,648.25
|
| Rate for Payer: Humana Commercial |
$1,474.75
|
| Rate for Payer: Humana KY Medicaid |
$596.67
|
| Rate for Payer: Kentucky WC Medicaid |
$602.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,422.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,280.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$520.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$608.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,526.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$225.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$537.85
|
| Rate for Payer: PHCS Commercial |
$1,665.60
|
| Rate for Payer: United Healthcare All Payer |
$1,526.80
|
|
|
TRAILBLAZER 0.014 ANGLED
|
Facility
|
OP
|
$2,039.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$265.14 |
| Max. Negotiated Rate |
$1,957.92 |
| Rate for Payer: Aetna Commercial |
$1,570.42
|
| Rate for Payer: Anthem Medicaid |
$701.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,590.81
|
| Rate for Payer: Cash Price |
$1,019.75
|
| Rate for Payer: Cigna Commercial |
$1,692.78
|
| Rate for Payer: First Health Commercial |
$1,937.52
|
| Rate for Payer: Humana Commercial |
$1,733.58
|
| Rate for Payer: Humana KY Medicaid |
$701.38
|
| Rate for Payer: Kentucky WC Medicaid |
$708.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,672.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,505.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$611.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$715.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,794.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,529.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$632.24
|
| Rate for Payer: PHCS Commercial |
$1,957.92
|
| Rate for Payer: United Healthcare All Payer |
$1,794.76
|
|
|
TRAILBLAZER 0.014 ANGLED
|
Facility
|
IP
|
$2,039.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$265.14 |
| Max. Negotiated Rate |
$1,957.92 |
| Rate for Payer: Aetna Commercial |
$1,570.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,590.81
|
| Rate for Payer: Cash Price |
$1,019.75
|
| Rate for Payer: Cigna Commercial |
$1,692.78
|
| Rate for Payer: First Health Commercial |
$1,937.52
|
| Rate for Payer: Humana Commercial |
$1,733.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,672.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,505.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$611.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,794.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,529.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$632.24
|
| Rate for Payer: PHCS Commercial |
$1,957.92
|
| Rate for Payer: United Healthcare All Payer |
$1,794.76
|
|
|
TRAILBLAZER 0.018
|
Facility
|
OP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem Medicaid |
$662.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Humana KY Medicaid |
$662.87
|
| Rate for Payer: Kentucky WC Medicaid |
$669.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$676.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
TRAILBLAZER 0.018
|
Facility
|
IP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
