|
TREK BALLOON OTW 2.5*12
|
Facility
|
IP
|
$1,547.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$1,485.60 |
| Rate for Payer: Aetna Commercial |
$1,191.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,207.05
|
| Rate for Payer: Cash Price |
$773.75
|
| Rate for Payer: Cigna Commercial |
$1,284.42
|
| Rate for Payer: First Health Commercial |
$1,470.12
|
| Rate for Payer: Humana Commercial |
$1,315.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,268.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,142.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,361.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,160.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$479.72
|
| Rate for Payer: PHCS Commercial |
$1,485.60
|
| Rate for Payer: United Healthcare All Payer |
$1,361.80
|
|
|
TREK BALLOON OTW 2.5*15
|
Facility
|
OP
|
$1,875.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
TREK BALLOON OTW 2.5*15
|
Facility
|
IP
|
$1,875.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
TREK BALLOON OTW 3*15
|
Facility
|
OP
|
$1,875.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
TREK BALLOON OTW 3*15
|
Facility
|
IP
|
$1,875.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
TREK BALLOON OTW 3*20
|
Facility
|
OP
|
$1,875.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
TREK BALLOON OTW 3*20
|
Facility
|
IP
|
$1,875.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
TRENDA 100MG VIAL
|
Facility
|
IP
|
$16,196.31
|
|
|
Service Code
|
HCPCS J9033
|
| Hospital Charge Code |
25002563
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,105.52 |
| Max. Negotiated Rate |
$15,548.46 |
| Rate for Payer: Aetna Commercial |
$12,471.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,633.12
|
| Rate for Payer: Cash Price |
$8,098.16
|
| Rate for Payer: Cigna Commercial |
$13,442.94
|
| Rate for Payer: First Health Commercial |
$15,386.49
|
| Rate for Payer: Humana Commercial |
$13,766.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,280.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,952.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,858.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,252.75
|
| Rate for Payer: Ohio Health Group HMO |
$12,147.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,239.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,105.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,020.86
|
| Rate for Payer: PHCS Commercial |
$15,548.46
|
| Rate for Payer: United Healthcare All Payer |
$14,252.75
|
|
|
TRENDA 100MG VIAL
|
Facility
|
OP
|
$16,196.31
|
|
|
Service Code
|
HCPCS J9033
|
| Hospital Charge Code |
25002563
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$15,548.46 |
| Rate for Payer: Aetna Commercial |
$12,471.16
|
| Rate for Payer: Anthem Medicaid |
$5,569.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,633.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.41
|
| Rate for Payer: Cash Price |
$8,098.16
|
| Rate for Payer: Cash Price |
$8,098.16
|
| Rate for Payer: Cigna Commercial |
$13,442.94
|
| Rate for Payer: First Health Commercial |
$15,386.49
|
| Rate for Payer: Humana Commercial |
$13,766.86
|
| Rate for Payer: Humana KY Medicaid |
$5,569.91
|
| Rate for Payer: Humana Medicare Advantage |
$9.19
|
| Rate for Payer: Kentucky WC Medicaid |
$5,626.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,280.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,952.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,681.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,252.75
|
| Rate for Payer: Ohio Health Group HMO |
$12,147.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,239.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,105.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,020.86
|
| Rate for Payer: PHCS Commercial |
$15,548.46
|
| Rate for Payer: United Healthcare All Payer |
$14,252.75
|
|
|
TRENTAL(PENTOXIFYLL 400MG/1TAB
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 904544861
|
| Hospital Charge Code |
25001582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
TRENTAL(PENTOXIFYLL 400MG/1TAB
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 904544861
|
| Hospital Charge Code |
25001582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
TRESIBA U-100 INSULIN PEN
|
Facility
|
OP
|
$184.90
|
|
|
Service Code
|
NDC 169266015
|
| Hospital Charge Code |
25001583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.04 |
| Max. Negotiated Rate |
$177.50 |
| Rate for Payer: Aetna Commercial |
$142.37
|
| Rate for Payer: Anthem Medicaid |
$63.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.22
|
| Rate for Payer: Cash Price |
$92.45
|
| Rate for Payer: Cigna Commercial |
$153.47
|
| Rate for Payer: First Health Commercial |
$175.66
|
| Rate for Payer: Humana Commercial |
$157.16
|
| Rate for Payer: Humana KY Medicaid |
$63.59
|
| Rate for Payer: Kentucky WC Medicaid |
$64.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.71
|
| Rate for Payer: Ohio Health Group HMO |
$138.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.32
|
| Rate for Payer: PHCS Commercial |
$177.50
|
| Rate for Payer: United Healthcare All Payer |
$162.71
|
|
|
TRESIBA U-100 INSULIN PEN
|
Facility
|
IP
|
$184.90
|
|
|
Service Code
|
NDC 169266015
|
| Hospital Charge Code |
25001583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.04 |
| Max. Negotiated Rate |
$177.50 |
| Rate for Payer: Aetna Commercial |
$142.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.22
|
| Rate for Payer: Cash Price |
$92.45
|
| Rate for Payer: Cigna Commercial |
$153.47
|
| Rate for Payer: First Health Commercial |
$175.66
|
| Rate for Payer: Humana Commercial |
$157.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.71
|
| Rate for Payer: Ohio Health Group HMO |
$138.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.32
|
| Rate for Payer: PHCS Commercial |
$177.50
|
| Rate for Payer: United Healthcare All Payer |
$162.71
|
|
|
TRESIBA U-200 INSULIN PEN
|
Facility
|
OP
|
$621.37
|
|
|
Service Code
|
NDC 169255013
|
| Hospital Charge Code |
25001584
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.78 |
| Max. Negotiated Rate |
$596.52 |
| Rate for Payer: Aetna Commercial |
$478.45
|
| Rate for Payer: Anthem Medicaid |
$213.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$484.67
|
| Rate for Payer: Cash Price |
$310.68
|
| Rate for Payer: Cigna Commercial |
$515.74
|
| Rate for Payer: First Health Commercial |
$590.30
|
| Rate for Payer: Humana Commercial |
$528.16
|
| Rate for Payer: Humana KY Medicaid |
$213.69
|
| Rate for Payer: Kentucky WC Medicaid |
$215.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$509.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$458.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$546.81
|
| Rate for Payer: Ohio Health Group HMO |
$466.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.62
|
| Rate for Payer: PHCS Commercial |
$596.52
|
| Rate for Payer: United Healthcare All Payer |
$546.81
|
|
|
TRESIBA U-200 INSULIN PEN
|
Facility
|
IP
|
$621.37
|
|
|
Service Code
|
NDC 169255013
|
| Hospital Charge Code |
25001584
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.78 |
| Max. Negotiated Rate |
$596.52 |
| Rate for Payer: Aetna Commercial |
$478.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$484.67
|
| Rate for Payer: Cash Price |
$310.68
|
| Rate for Payer: Cigna Commercial |
$515.74
|
| Rate for Payer: First Health Commercial |
$590.30
|
| Rate for Payer: Humana Commercial |
$528.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$509.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$458.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$546.81
|
| Rate for Payer: Ohio Health Group HMO |
$466.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.62
|
| Rate for Payer: PHCS Commercial |
$596.52
|
| Rate for Payer: United Healthcare All Payer |
$546.81
|
|
|
TRETINOIN 0.05% REFISSA 20G
|
Professional
|
Both
|
$35.00
|
|
| Hospital Charge Code |
22200160
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$35.00
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
|
|
TRETINOIN 0.1%
|
Professional
|
Both
|
$99.00
|
|
| Hospital Charge Code |
22200158
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$99.00
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Multiplan PHCS |
$59.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$69.30
|
| Rate for Payer: UHCCP Medicaid |
$34.65
|
|
|
TRIAD HYDROPHYLIC PASTE 170gm
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 11701003132
|
| Hospital Charge Code |
25004456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Anthem Medicaid |
$1.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cigna Commercial |
$3.32
|
| Rate for Payer: First Health Commercial |
$3.80
|
| Rate for Payer: Humana Commercial |
$3.40
|
| Rate for Payer: Humana KY Medicaid |
$1.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.52
|
| Rate for Payer: Ohio Health Group HMO |
$3.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.24
|
| Rate for Payer: PHCS Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Payer |
$3.52
|
|
|
TRIAD HYDROPHYLIC PASTE 170gm
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 11701003132
|
| Hospital Charge Code |
25004456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cigna Commercial |
$3.32
|
| Rate for Payer: First Health Commercial |
$3.80
|
| Rate for Payer: Humana Commercial |
$3.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.52
|
| Rate for Payer: Ohio Health Group HMO |
$3.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.24
|
| Rate for Payer: PHCS Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Payer |
$3.52
|
|
|
TRIAD HYDROPHYLIC PASTE 71gm
|
Facility
|
IP
|
$5.15
|
|
|
Service Code
|
NDC 11701003133
|
| Hospital Charge Code |
25004438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$3.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.02
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.27
|
| Rate for Payer: First Health Commercial |
$4.89
|
| Rate for Payer: Humana Commercial |
$4.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.53
|
| Rate for Payer: Ohio Health Group HMO |
$3.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.60
|
| Rate for Payer: PHCS Commercial |
$4.94
|
| Rate for Payer: United Healthcare All Payer |
$4.53
|
|
|
TRIAD HYDROPHYLIC PASTE 71gm
|
Facility
|
OP
|
$5.15
|
|
|
Service Code
|
NDC 11701003133
|
| Hospital Charge Code |
25004438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$3.97
|
| Rate for Payer: Anthem Medicaid |
$1.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.02
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.27
|
| Rate for Payer: First Health Commercial |
$4.89
|
| Rate for Payer: Humana Commercial |
$4.38
|
| Rate for Payer: Humana KY Medicaid |
$1.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.53
|
| Rate for Payer: Ohio Health Group HMO |
$3.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.60
|
| Rate for Payer: PHCS Commercial |
$4.94
|
| Rate for Payer: United Healthcare All Payer |
$4.53
|
|
|
TRIAL ANTR STABBRG TRL 10X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 10X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 12X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 12X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
