|
TIE-IN TRAPEZIUM KIT SIZE 1
|
Facility
|
IP
|
$12,208.91
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,662.67 |
| Max. Negotiated Rate |
$11,720.55 |
| Rate for Payer: Aetna Commercial |
$9,400.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,522.95
|
| Rate for Payer: Cash Price |
$6,104.46
|
| Rate for Payer: Cigna Commercial |
$10,133.40
|
| Rate for Payer: First Health Commercial |
$11,598.46
|
| Rate for Payer: Humana Commercial |
$10,377.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,011.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,010.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,662.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,743.84
|
| Rate for Payer: Ohio Health Group HMO |
$9,156.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,767.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,621.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,424.15
|
| Rate for Payer: PHCS Commercial |
$11,720.55
|
| Rate for Payer: United Healthcare All Payer |
$10,743.84
|
|
|
TIE-IN TRAPEZIUM KIT SIZE 2
|
Facility
|
OP
|
$11,038.18
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,311.45 |
| Max. Negotiated Rate |
$10,596.65 |
| Rate for Payer: Aetna Commercial |
$8,499.40
|
| Rate for Payer: Anthem Medicaid |
$3,796.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,609.78
|
| Rate for Payer: Cash Price |
$5,519.09
|
| Rate for Payer: Cigna Commercial |
$9,161.69
|
| Rate for Payer: First Health Commercial |
$10,486.27
|
| Rate for Payer: Humana Commercial |
$9,382.45
|
| Rate for Payer: Humana KY Medicaid |
$3,796.03
|
| Rate for Payer: Kentucky WC Medicaid |
$3,834.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,051.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,146.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,311.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,872.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,713.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,278.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,830.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,603.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,616.34
|
| Rate for Payer: PHCS Commercial |
$10,596.65
|
| Rate for Payer: United Healthcare All Payer |
$9,713.60
|
|
|
TIE-IN TRAPEZIUM KIT SIZE 2
|
Facility
|
IP
|
$11,038.18
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,311.45 |
| Max. Negotiated Rate |
$10,596.65 |
| Rate for Payer: Aetna Commercial |
$8,499.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,609.78
|
| Rate for Payer: Cash Price |
$5,519.09
|
| Rate for Payer: Cigna Commercial |
$9,161.69
|
| Rate for Payer: First Health Commercial |
$10,486.27
|
| Rate for Payer: Humana Commercial |
$9,382.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,051.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,146.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,311.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,713.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,278.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,830.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,603.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,616.34
|
| Rate for Payer: PHCS Commercial |
$10,596.65
|
| Rate for Payer: United Healthcare All Payer |
$9,713.60
|
|
|
TIE-IN TRAPEZIUM KIT SIZE 3
|
Facility
|
IP
|
$11,038.18
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,311.45 |
| Max. Negotiated Rate |
$10,596.65 |
| Rate for Payer: Aetna Commercial |
$8,499.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,609.78
|
| Rate for Payer: Cash Price |
$5,519.09
|
| Rate for Payer: Cigna Commercial |
$9,161.69
|
| Rate for Payer: First Health Commercial |
$10,486.27
|
| Rate for Payer: Humana Commercial |
$9,382.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,051.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,146.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,311.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,713.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,278.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,830.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,603.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,616.34
|
| Rate for Payer: PHCS Commercial |
$10,596.65
|
| Rate for Payer: United Healthcare All Payer |
$9,713.60
|
|
|
TIE-IN TRAPEZIUM KIT SIZE 3
|
Facility
|
OP
|
$11,038.18
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,311.45 |
| Max. Negotiated Rate |
$10,596.65 |
| Rate for Payer: Aetna Commercial |
$8,499.40
|
| Rate for Payer: Anthem Medicaid |
$3,796.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,609.78
|
| Rate for Payer: Cash Price |
$5,519.09
|
| Rate for Payer: Cigna Commercial |
$9,161.69
|
| Rate for Payer: First Health Commercial |
$10,486.27
|
| Rate for Payer: Humana Commercial |
$9,382.45
|
| Rate for Payer: Humana KY Medicaid |
$3,796.03
|
| Rate for Payer: Kentucky WC Medicaid |
$3,834.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,051.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,146.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,311.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,872.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,713.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,278.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,830.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,603.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,616.34
|
| Rate for Payer: PHCS Commercial |
$10,596.65
|
| Rate for Payer: United Healthcare All Payer |
$9,713.60
|
|
|
TIGAN (TRIMETHOBENZ. 200MG/2ML
|
Facility
|
OP
|
$329.63
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
25002390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.89 |
| Max. Negotiated Rate |
$316.44 |
| Rate for Payer: Aetna Commercial |
$253.82
|
| Rate for Payer: Anthem Medicaid |
$113.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.11
|
| Rate for Payer: Cash Price |
$164.82
|
| Rate for Payer: Cigna Commercial |
$273.59
|
| Rate for Payer: First Health Commercial |
$313.15
|
| Rate for Payer: Humana Commercial |
$280.19
|
| Rate for Payer: Humana KY Medicaid |
$113.36
|
| Rate for Payer: Kentucky WC Medicaid |
$114.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.07
|
| Rate for Payer: Ohio Health Group HMO |
$247.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.44
|
| Rate for Payer: PHCS Commercial |
$316.44
|
| Rate for Payer: United Healthcare All Payer |
$290.07
|
|
|
TIGAN (TRIMETHOBENZ. 200MG/2ML
|
Facility
|
IP
|
$329.63
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
25002390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.89 |
| Max. Negotiated Rate |
$316.44 |
| Rate for Payer: Aetna Commercial |
$253.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.11
|
| Rate for Payer: Cash Price |
$164.82
|
| Rate for Payer: Cigna Commercial |
$273.59
|
| Rate for Payer: First Health Commercial |
$313.15
|
| Rate for Payer: Humana Commercial |
$280.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.07
|
| Rate for Payer: Ohio Health Group HMO |
$247.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.44
|
| Rate for Payer: PHCS Commercial |
$316.44
|
| Rate for Payer: United Healthcare All Payer |
$290.07
|
|
|
TIGECYCLINE 1mg (50mg SDV)
|
Facility
|
OP
|
$572.25
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
25002387
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.68 |
| Max. Negotiated Rate |
$549.36 |
| Rate for Payer: Aetna Commercial |
$440.63
|
| Rate for Payer: Anthem Medicaid |
$196.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$446.36
|
| Rate for Payer: Cash Price |
$286.12
|
| Rate for Payer: Cigna Commercial |
$474.97
|
| Rate for Payer: First Health Commercial |
$543.64
|
| Rate for Payer: Humana Commercial |
$486.41
|
| Rate for Payer: Humana KY Medicaid |
$196.80
|
| Rate for Payer: Kentucky WC Medicaid |
$198.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$469.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$422.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$200.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$503.58
|
| Rate for Payer: Ohio Health Group HMO |
$429.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$497.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$394.85
|
| Rate for Payer: PHCS Commercial |
$549.36
|
| Rate for Payer: United Healthcare All Payer |
$503.58
|
|
|
TIGECYCLINE 1mg (50mg SDV)
|
Facility
|
IP
|
$572.25
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
25002387
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.68 |
| Max. Negotiated Rate |
$549.36 |
| Rate for Payer: Aetna Commercial |
$440.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$446.36
|
| Rate for Payer: Cash Price |
$286.12
|
| Rate for Payer: Cigna Commercial |
$474.97
|
| Rate for Payer: First Health Commercial |
$543.64
|
| Rate for Payer: Humana Commercial |
$486.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$469.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$422.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$503.58
|
| Rate for Payer: Ohio Health Group HMO |
$429.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$497.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$394.85
|
| Rate for Payer: PHCS Commercial |
$549.36
|
| Rate for Payer: United Healthcare All Payer |
$503.58
|
|
|
TIGEREYE CTO CROSSING CATHETER
|
Facility
|
OP
|
$12,656.65
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,796.99 |
| Max. Negotiated Rate |
$12,150.38 |
| Rate for Payer: Aetna Commercial |
$9,745.62
|
| Rate for Payer: Anthem Medicaid |
$4,352.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,872.19
|
| Rate for Payer: Cash Price |
$6,328.32
|
| Rate for Payer: Cigna Commercial |
$10,505.02
|
| Rate for Payer: First Health Commercial |
$12,023.82
|
| Rate for Payer: Humana Commercial |
$10,758.15
|
| Rate for Payer: Humana KY Medicaid |
$4,352.62
|
| Rate for Payer: Kentucky WC Medicaid |
$4,396.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,378.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,340.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,796.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,439.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,137.85
|
| Rate for Payer: Ohio Health Group HMO |
$9,492.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,125.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,011.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,733.09
|
| Rate for Payer: PHCS Commercial |
$12,150.38
|
| Rate for Payer: United Healthcare All Payer |
$11,137.85
|
|
|
TIGEREYE CTO CROSSING CATHETER
|
Facility
|
IP
|
$12,656.65
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,796.99 |
| Max. Negotiated Rate |
$12,150.38 |
| Rate for Payer: Aetna Commercial |
$9,745.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,872.19
|
| Rate for Payer: Cash Price |
$6,328.32
|
| Rate for Payer: Cigna Commercial |
$10,505.02
|
| Rate for Payer: First Health Commercial |
$12,023.82
|
| Rate for Payer: Humana Commercial |
$10,758.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,378.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,340.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,796.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,137.85
|
| Rate for Payer: Ohio Health Group HMO |
$9,492.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,125.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,011.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,733.09
|
| Rate for Payer: PHCS Commercial |
$12,150.38
|
| Rate for Payer: United Healthcare All Payer |
$11,137.85
|
|
|
TIGERLOOP #2 WT/GR ST AR-7234T
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
TIGERLOOP #2 WT/GR ST AR-7234T
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
TIGER RADIAL CATH 5FR 4.0
|
Facility
|
OP
|
$1,130.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem Medicaid |
$388.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Humana KY Medicaid |
$388.61
|
| Rate for Payer: Kentucky WC Medicaid |
$392.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
TIGER RADIAL CATH 5FR 4.0
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
TIGHTROPE 2 ABS OPEN
|
Facility
|
IP
|
$3,161.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.47 |
| Max. Negotiated Rate |
$3,035.10 |
| Rate for Payer: Aetna Commercial |
$2,434.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.02
|
| Rate for Payer: Cash Price |
$1,580.78
|
| Rate for Payer: Cigna Commercial |
$2,624.09
|
| Rate for Payer: First Health Commercial |
$3,003.48
|
| Rate for Payer: Humana Commercial |
$2,687.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.17
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.48
|
| Rate for Payer: PHCS Commercial |
$3,035.10
|
| Rate for Payer: United Healthcare All Payer |
$2,782.17
|
|
|
TIGHTROPE 2 ABS OPEN
|
Facility
|
OP
|
$3,161.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.47 |
| Max. Negotiated Rate |
$3,035.10 |
| Rate for Payer: Aetna Commercial |
$2,434.40
|
| Rate for Payer: Anthem Medicaid |
$1,087.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.02
|
| Rate for Payer: Cash Price |
$1,580.78
|
| Rate for Payer: Cigna Commercial |
$2,624.09
|
| Rate for Payer: First Health Commercial |
$3,003.48
|
| Rate for Payer: Humana Commercial |
$2,687.33
|
| Rate for Payer: Humana KY Medicaid |
$1,087.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,098.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,109.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.17
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.48
|
| Rate for Payer: PHCS Commercial |
$3,035.10
|
| Rate for Payer: United Healthcare All Payer |
$2,782.17
|
|
|
TIGHTROPE II BTB RECON IB
|
Facility
|
OP
|
$4,539.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,361.91 |
| Max. Negotiated Rate |
$4,358.10 |
| Rate for Payer: Aetna Commercial |
$3,495.56
|
| Rate for Payer: Anthem Medicaid |
$1,561.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,540.96
|
| Rate for Payer: Cash Price |
$2,269.84
|
| Rate for Payer: Cigna Commercial |
$3,767.94
|
| Rate for Payer: First Health Commercial |
$4,312.71
|
| Rate for Payer: Humana Commercial |
$3,858.74
|
| Rate for Payer: Humana KY Medicaid |
$1,561.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,577.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,722.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,350.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,361.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,592.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,994.93
|
| Rate for Payer: Ohio Health Group HMO |
$3,404.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,631.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,949.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,132.39
|
| Rate for Payer: PHCS Commercial |
$4,358.10
|
| Rate for Payer: United Healthcare All Payer |
$3,994.93
|
|
|
TIGHTROPE II BTB RECON IB
|
Facility
|
IP
|
$4,539.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,361.91 |
| Max. Negotiated Rate |
$4,358.10 |
| Rate for Payer: Aetna Commercial |
$3,495.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,540.96
|
| Rate for Payer: Cash Price |
$2,269.84
|
| Rate for Payer: Cigna Commercial |
$3,767.94
|
| Rate for Payer: First Health Commercial |
$4,312.71
|
| Rate for Payer: Humana Commercial |
$3,858.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,722.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,350.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,361.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,994.93
|
| Rate for Payer: Ohio Health Group HMO |
$3,404.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,631.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,949.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,132.39
|
| Rate for Payer: PHCS Commercial |
$4,358.10
|
| Rate for Payer: United Healthcare All Payer |
$3,994.93
|
|
|
TIKOSYN 125 MCG CAPSULE
|
Facility
|
IP
|
$9.33
|
|
|
Service Code
|
NDC 59651011860
|
| Hospital Charge Code |
25003522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.86
|
| Rate for Payer: Humana Commercial |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.21
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.44
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
TIKOSYN 125 MCG CAPSULE
|
Facility
|
OP
|
$9.33
|
|
|
Service Code
|
NDC 59651011860
|
| Hospital Charge Code |
25003522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem Medicaid |
$3.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.86
|
| Rate for Payer: Humana Commercial |
$7.93
|
| Rate for Payer: Humana KY Medicaid |
$3.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.21
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.44
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
TIKOSYN 250MCG CAPSULE
|
Facility
|
OP
|
$28.19
|
|
|
Service Code
|
NDC 69581060
|
| Hospital Charge Code |
25001547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$27.06 |
| Rate for Payer: Aetna Commercial |
$21.71
|
| Rate for Payer: Anthem Medicaid |
$9.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.99
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$23.40
|
| Rate for Payer: First Health Commercial |
$26.78
|
| Rate for Payer: Humana Commercial |
$23.96
|
| Rate for Payer: Humana KY Medicaid |
$9.69
|
| Rate for Payer: Kentucky WC Medicaid |
$9.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.81
|
| Rate for Payer: Ohio Health Group HMO |
$21.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.45
|
| Rate for Payer: PHCS Commercial |
$27.06
|
| Rate for Payer: United Healthcare All Payer |
$24.81
|
|
|
TIKOSYN 250MCG CAPSULE
|
Facility
|
IP
|
$28.19
|
|
|
Service Code
|
NDC 69581060
|
| Hospital Charge Code |
25001547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$27.06 |
| Rate for Payer: Aetna Commercial |
$21.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.99
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$23.40
|
| Rate for Payer: First Health Commercial |
$26.78
|
| Rate for Payer: Humana Commercial |
$23.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.81
|
| Rate for Payer: Ohio Health Group HMO |
$21.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.45
|
| Rate for Payer: PHCS Commercial |
$27.06
|
| Rate for Payer: United Healthcare All Payer |
$24.81
|
|
|
TIKOSYN 500MCG CAPSULE
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 16729049212
|
| Hospital Charge Code |
25001548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna Commercial |
$7.39
|
| Rate for Payer: Anthem Medicaid |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.49
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.97
|
| Rate for Payer: First Health Commercial |
$9.12
|
| Rate for Payer: Humana Commercial |
$8.16
|
| Rate for Payer: Humana KY Medicaid |
$3.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.45
|
| Rate for Payer: Ohio Health Group HMO |
$7.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.62
|
| Rate for Payer: PHCS Commercial |
$9.22
|
| Rate for Payer: United Healthcare All Payer |
$8.45
|
|
|
TIKOSYN 500MCG CAPSULE
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 16729049212
|
| Hospital Charge Code |
25001548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna Commercial |
$7.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.49
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.97
|
| Rate for Payer: First Health Commercial |
$9.12
|
| Rate for Payer: Humana Commercial |
$8.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.45
|
| Rate for Payer: Ohio Health Group HMO |
$7.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.62
|
| Rate for Payer: PHCS Commercial |
$9.22
|
| Rate for Payer: United Healthcare All Payer |
$8.45
|
|
