|
TITAN CHP 75 LNGTH 16 THRD
|
Facility
|
OP
|
$3,341.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,002.47 |
| Max. Negotiated Rate |
$3,207.90 |
| Rate for Payer: Aetna Commercial |
$2,573.00
|
| Rate for Payer: Anthem Medicaid |
$1,149.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,606.42
|
| Rate for Payer: Cash Price |
$1,670.78
|
| Rate for Payer: Cigna Commercial |
$2,773.49
|
| Rate for Payer: First Health Commercial |
$3,174.48
|
| Rate for Payer: Humana Commercial |
$2,840.33
|
| Rate for Payer: Humana KY Medicaid |
$1,149.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,160.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,740.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,466.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,002.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,172.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,940.57
|
| Rate for Payer: Ohio Health Group HMO |
$2,506.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,673.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,907.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,305.68
|
| Rate for Payer: PHCS Commercial |
$3,207.90
|
| Rate for Payer: United Healthcare All Payer |
$2,940.57
|
|
|
TITAN CHP 75 LNGTH 16 THRD
|
Facility
|
IP
|
$3,341.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,002.47 |
| Max. Negotiated Rate |
$3,207.90 |
| Rate for Payer: Aetna Commercial |
$2,573.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,606.42
|
| Rate for Payer: Cash Price |
$1,670.78
|
| Rate for Payer: Cigna Commercial |
$2,773.49
|
| Rate for Payer: First Health Commercial |
$3,174.48
|
| Rate for Payer: Humana Commercial |
$2,840.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,740.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,466.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,002.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,940.57
|
| Rate for Payer: Ohio Health Group HMO |
$2,506.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,673.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,907.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,305.68
|
| Rate for Payer: PHCS Commercial |
$3,207.90
|
| Rate for Payer: United Healthcare All Payer |
$2,940.57
|
|
|
TITAN PENILE PROST ASSEMBLY KI
|
Facility
|
OP
|
$3,331.25
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.38 |
| Max. Negotiated Rate |
$3,198.00 |
| Rate for Payer: Aetna Commercial |
$2,565.06
|
| Rate for Payer: Anthem Medicaid |
$1,145.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,598.38
|
| Rate for Payer: Cash Price |
$1,665.62
|
| Rate for Payer: Cigna Commercial |
$2,764.94
|
| Rate for Payer: First Health Commercial |
$3,164.69
|
| Rate for Payer: Humana Commercial |
$2,831.56
|
| Rate for Payer: Humana KY Medicaid |
$1,145.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,157.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,731.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,458.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$999.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,168.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,931.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,498.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,665.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,898.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.56
|
| Rate for Payer: PHCS Commercial |
$3,198.00
|
| Rate for Payer: United Healthcare All Payer |
$2,931.50
|
|
|
TITAN PENILE PROST ASSEMBLY KI
|
Facility
|
IP
|
$3,331.25
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.38 |
| Max. Negotiated Rate |
$3,198.00 |
| Rate for Payer: Aetna Commercial |
$2,565.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,598.38
|
| Rate for Payer: Cash Price |
$1,665.62
|
| Rate for Payer: Cigna Commercial |
$2,764.94
|
| Rate for Payer: First Health Commercial |
$3,164.69
|
| Rate for Payer: Humana Commercial |
$2,831.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,731.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,458.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$999.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,931.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,498.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,665.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,898.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.56
|
| Rate for Payer: PHCS Commercial |
$3,198.00
|
| Rate for Payer: United Healthcare All Payer |
$2,931.50
|
|
|
TITAN PENILE PROSTHESES 14CM
|
Facility
|
IP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 14CM
|
Facility
|
OP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem Medicaid |
$7,812.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Humana KY Medicaid |
$7,812.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,892.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,969.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 16CM
|
Facility
|
OP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem Medicaid |
$7,812.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Humana KY Medicaid |
$7,812.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,892.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,969.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 16CM
|
Facility
|
IP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 18CM
|
Facility
|
OP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem Medicaid |
$7,812.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Humana KY Medicaid |
$7,812.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,892.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,969.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 18CM
|
Facility
|
IP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 20CM
|
Facility
|
IP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 20CM
|
Facility
|
OP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem Medicaid |
$7,812.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Humana KY Medicaid |
$7,812.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,892.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,969.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 22CM
|
Facility
|
IP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TITAN PENILE PROSTHESES 22CM
|
Facility
|
OP
|
$22,718.75
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,815.62 |
| Max. Negotiated Rate |
$21,810.00 |
| Rate for Payer: Aetna Commercial |
$17,493.44
|
| Rate for Payer: Anthem Medicaid |
$7,812.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,720.62
|
| Rate for Payer: Cash Price |
$11,359.38
|
| Rate for Payer: Cigna Commercial |
$18,856.56
|
| Rate for Payer: First Health Commercial |
$21,582.81
|
| Rate for Payer: Humana Commercial |
$19,310.94
|
| Rate for Payer: Humana KY Medicaid |
$7,812.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,892.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,629.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,766.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,815.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,969.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,992.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,039.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,765.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,675.94
|
| Rate for Payer: PHCS Commercial |
$21,810.00
|
| Rate for Payer: United Healthcare All Payer |
$19,992.50
|
|
|
TIVICAY 50MG TABLET
|
Facility
|
OP
|
$149.51
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
25003525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$143.53 |
| Rate for Payer: Aetna Commercial |
$115.12
|
| Rate for Payer: Anthem Medicaid |
$51.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$116.62
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cigna Commercial |
$124.09
|
| Rate for Payer: First Health Commercial |
$142.03
|
| Rate for Payer: Humana Commercial |
$127.08
|
| Rate for Payer: Humana KY Medicaid |
$51.42
|
| Rate for Payer: Kentucky WC Medicaid |
$51.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.57
|
| Rate for Payer: Ohio Health Group HMO |
$112.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$119.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.16
|
| Rate for Payer: PHCS Commercial |
$143.53
|
| Rate for Payer: United Healthcare All Payer |
$131.57
|
|
|
TIVICAY 50MG TABLET
|
Facility
|
IP
|
$149.51
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
25003525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$143.53 |
| Rate for Payer: Aetna Commercial |
$115.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$116.62
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cigna Commercial |
$124.09
|
| Rate for Payer: First Health Commercial |
$142.03
|
| Rate for Payer: Humana Commercial |
$127.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.57
|
| Rate for Payer: Ohio Health Group HMO |
$112.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$119.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.16
|
| Rate for Payer: PHCS Commercial |
$143.53
|
| Rate for Payer: United Healthcare All Payer |
$131.57
|
|
|
TLA INTRODUCER NEEDLE & SHEATH
|
Facility
|
OP
|
$566.08
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$169.82 |
| Max. Negotiated Rate |
$543.44 |
| Rate for Payer: Aetna Commercial |
$435.88
|
| Rate for Payer: Anthem Medicaid |
$194.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$441.54
|
| Rate for Payer: Cash Price |
$283.04
|
| Rate for Payer: Cigna Commercial |
$469.85
|
| Rate for Payer: First Health Commercial |
$537.78
|
| Rate for Payer: Humana Commercial |
$481.17
|
| Rate for Payer: Humana KY Medicaid |
$194.67
|
| Rate for Payer: Kentucky WC Medicaid |
$196.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$464.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$417.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$498.15
|
| Rate for Payer: Ohio Health Group HMO |
$424.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$452.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$492.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.60
|
| Rate for Payer: PHCS Commercial |
$543.44
|
| Rate for Payer: United Healthcare All Payer |
$498.15
|
|
|
TLA INTRODUCER NEEDLE & SHEATH
|
Facility
|
IP
|
$566.08
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$169.82 |
| Max. Negotiated Rate |
$543.44 |
| Rate for Payer: Aetna Commercial |
$435.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$441.54
|
| Rate for Payer: Cash Price |
$283.04
|
| Rate for Payer: Cigna Commercial |
$469.85
|
| Rate for Payer: First Health Commercial |
$537.78
|
| Rate for Payer: Humana Commercial |
$481.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$464.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$417.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$498.15
|
| Rate for Payer: Ohio Health Group HMO |
$424.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$452.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$492.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.60
|
| Rate for Payer: PHCS Commercial |
$543.44
|
| Rate for Payer: United Healthcare All Payer |
$498.15
|
|
|
TLH UTERUS 250 G OR LESS
|
Professional
|
Both
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
76102240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.50 |
| Max. Negotiated Rate |
$1,398.46 |
| Rate for Payer: Aetna Commercial |
$1,398.46
|
| Rate for Payer: Ambetter Exchange |
$765.39
|
| Rate for Payer: Anthem Medicaid |
$712.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$765.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$765.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$918.47
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,311.59
|
| Rate for Payer: Healthspan PPO |
$1,354.06
|
| Rate for Payer: Humana Medicaid |
$712.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,202.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$765.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$765.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$727.23
|
| Rate for Payer: Molina Healthcare Passport |
$712.97
|
| Rate for Payer: Multiplan PHCS |
$1,182.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$995.01
|
| Rate for Payer: UHCCP Medicaid |
$689.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$720.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$765.39
|
|
|
TLH UTERUS 250 G OR LESS
|
Facility
|
OP
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
76102240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$677.48 |
| Max. Negotiated Rate |
$13,467.66 |
| Rate for Payer: Aetna Commercial |
$1,516.90
|
| Rate for Payer: Anthem Medicaid |
$677.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,619.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,536.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,467.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,986.68
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,635.10
|
| Rate for Payer: First Health Commercial |
$1,871.50
|
| Rate for Payer: Humana Commercial |
$1,674.50
|
| Rate for Payer: Humana KY Medicaid |
$677.48
|
| Rate for Payer: Humana Medicare Advantage |
$9,619.76
|
| Rate for Payer: Kentucky WC Medicaid |
$684.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,615.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,453.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,543.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$691.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,733.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,477.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,576.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,359.30
|
| Rate for Payer: PHCS Commercial |
$1,891.20
|
| Rate for Payer: United Healthcare All Payer |
$1,733.60
|
|
|
TLH UTERUS 250 G OR LESS
|
Facility
|
IP
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
76102240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$591.00 |
| Max. Negotiated Rate |
$1,891.20 |
| Rate for Payer: Aetna Commercial |
$1,516.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,536.60
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,635.10
|
| Rate for Payer: First Health Commercial |
$1,871.50
|
| Rate for Payer: Humana Commercial |
$1,674.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,615.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,453.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$591.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,733.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,477.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,576.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,359.30
|
| Rate for Payer: PHCS Commercial |
$1,891.20
|
| Rate for Payer: United Healthcare All Payer |
$1,733.60
|
|
|
TLH UTERUS 250 G OR LESS(P
|
Professional
|
Both
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
761P2240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.50 |
| Max. Negotiated Rate |
$1,398.46 |
| Rate for Payer: Aetna Commercial |
$1,398.46
|
| Rate for Payer: Ambetter Exchange |
$765.39
|
| Rate for Payer: Anthem Medicaid |
$712.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$765.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$765.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$918.47
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,311.59
|
| Rate for Payer: Healthspan PPO |
$1,354.06
|
| Rate for Payer: Humana Medicaid |
$712.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,202.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$765.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$765.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$727.23
|
| Rate for Payer: Molina Healthcare Passport |
$712.97
|
| Rate for Payer: Multiplan PHCS |
$1,182.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$995.01
|
| Rate for Payer: UHCCP Medicaid |
$689.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$720.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$765.39
|
|
|
TLH UTERUS OVER 250 G
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
360P1275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$1,741.69 |
| Rate for Payer: Aetna Commercial |
$1,741.69
|
| Rate for Payer: Ambetter Exchange |
$987.11
|
| Rate for Payer: Anthem Medicaid |
$886.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$987.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$987.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,184.53
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,629.36
|
| Rate for Payer: Healthspan PPO |
$1,686.40
|
| Rate for Payer: Humana Medicaid |
$886.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,496.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$987.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$903.96
|
| Rate for Payer: Molina Healthcare Passport |
$886.24
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,283.24
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$895.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$987.11
|
|
|
TLH UTERUS OVER 250 G
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
36001275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$431.59 |
| Max. Negotiated Rate |
$13,467.66 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem Medicaid |
$431.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,619.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,467.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,986.68
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Humana KY Medicaid |
$431.59
|
| Rate for Payer: Humana Medicare Advantage |
$9,619.76
|
| Rate for Payer: Kentucky WC Medicaid |
$435.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,543.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$440.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,091.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$865.95
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
TLH UTERUS OVER 250 G
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
36001275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$376.50 |
| Max. Negotiated Rate |
$1,204.80 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,091.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$865.95
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
