|
TRACHEOTOMY
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 31600
|
| Hospital Charge Code |
41000028
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
TRACHEOTOMY
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 31600
|
| Hospital Charge Code |
41000028
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$257.93 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.93
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
TRACHEOTOMY
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 31600
|
| Hospital Charge Code |
41000028
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$230.38 |
| Max. Negotiated Rate |
$660.05 |
| Rate for Payer: Aetna Commercial |
$660.05
|
| Rate for Payer: Ambetter Exchange |
$287.68
|
| Rate for Payer: Anthem Medicaid |
$230.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$287.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$287.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.22
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$604.18
|
| Rate for Payer: Healthspan PPO |
$515.35
|
| Rate for Payer: Humana Medicaid |
$230.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$521.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$287.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$234.99
|
| Rate for Payer: Molina Healthcare Passport |
$230.38
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$373.98
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$232.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$287.68
|
|
|
TRACHEOTOMY(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 31600
|
| Hospital Charge Code |
410P0028
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$230.38 |
| Max. Negotiated Rate |
$660.05 |
| Rate for Payer: Aetna Commercial |
$660.05
|
| Rate for Payer: Ambetter Exchange |
$287.68
|
| Rate for Payer: Anthem Medicaid |
$230.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$287.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$287.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.22
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$604.18
|
| Rate for Payer: Healthspan PPO |
$515.35
|
| Rate for Payer: Humana Medicaid |
$230.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$521.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$287.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$234.99
|
| Rate for Payer: Molina Healthcare Passport |
$230.38
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$373.98
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$232.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$287.68
|
|
|
TRACHEOTOMY TUBE CHANGE OR MAC
|
Professional
|
Both
|
$814.00
|
|
|
Service Code
|
HCPCS 31899
|
| Hospital Charge Code |
76102972
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$569.80 |
| Rate for Payer: Cash Price |
$407.00
|
| Rate for Payer: Cash Price |
$407.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$488.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$569.80
|
| Rate for Payer: UHCCP Medicaid |
$284.90
|
|
|
TRACHOMY, FENESTR PX WSKI FLAP
|
Professional
|
Both
|
$1,552.00
|
|
|
Service Code
|
HCPCS 31610
|
| Hospital Charge Code |
41000030
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$432.19 |
| Max. Negotiated Rate |
$1,153.23 |
| Rate for Payer: Aetna Commercial |
$1,099.04
|
| Rate for Payer: Ambetter Exchange |
$887.10
|
| Rate for Payer: Anthem Medicaid |
$432.19
|
| Rate for Payer: Buckeye Individual/Medicaid |
$887.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$887.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.52
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,004.48
|
| Rate for Payer: Healthspan PPO |
$858.10
|
| Rate for Payer: Humana Medicaid |
$432.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$908.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$887.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$887.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$931.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,153.23
|
| Rate for Payer: UHCCP Medicaid |
$543.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$887.10
|
|
|
TRACHOMY, FENESTR PX WSKI FLAP
|
Facility
|
OP
|
$1,552.00
|
|
|
Service Code
|
HCPCS 31610
|
| Hospital Charge Code |
41000030
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$533.73 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$1,195.04
|
| Rate for Payer: Anthem Medicaid |
$533.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,210.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,288.16
|
| Rate for Payer: First Health Commercial |
$1,474.40
|
| Rate for Payer: Humana Commercial |
$1,319.20
|
| Rate for Payer: Humana KY Medicaid |
$533.73
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Kentucky WC Medicaid |
$539.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,272.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,145.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$544.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,365.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,164.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,241.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,350.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.88
|
| Rate for Payer: PHCS Commercial |
$1,489.92
|
| Rate for Payer: United Healthcare All Payer |
$1,365.76
|
|
|
TRACHOMY, FENESTR PX WSKI FLAP
|
Facility
|
IP
|
$1,552.00
|
|
|
Service Code
|
HCPCS 31610
|
| Hospital Charge Code |
41000030
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$465.60 |
| Max. Negotiated Rate |
$1,489.92 |
| Rate for Payer: Aetna Commercial |
$1,195.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,210.56
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,288.16
|
| Rate for Payer: First Health Commercial |
$1,474.40
|
| Rate for Payer: Humana Commercial |
$1,319.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,272.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,145.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$465.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,365.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,164.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,241.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,350.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.88
|
| Rate for Payer: PHCS Commercial |
$1,489.92
|
| Rate for Payer: United Healthcare All Payer |
$1,365.76
|
|
|
TRACHOMY, FENESTR PX WSKI FLAP
|
Professional
|
Both
|
$1,552.00
|
|
|
Service Code
|
HCPCS 31610
|
| Hospital Charge Code |
410P0030
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$432.19 |
| Max. Negotiated Rate |
$1,153.23 |
| Rate for Payer: Aetna Commercial |
$1,099.04
|
| Rate for Payer: Ambetter Exchange |
$887.10
|
| Rate for Payer: Anthem Medicaid |
$432.19
|
| Rate for Payer: Buckeye Individual/Medicaid |
$887.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$887.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.52
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cash Price |
$776.00
|
| Rate for Payer: Cigna Commercial |
$1,004.48
|
| Rate for Payer: Healthspan PPO |
$858.10
|
| Rate for Payer: Humana Medicaid |
$432.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$908.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$887.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$887.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$931.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,153.23
|
| Rate for Payer: UHCCP Medicaid |
$543.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$887.10
|
|
|
TRACH PERC KIT BLUE RHINO SZ 6
|
Facility
|
IP
|
$3,837.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,151.25 |
| Max. Negotiated Rate |
$3,684.00 |
| Rate for Payer: Aetna Commercial |
$2,954.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.25
|
| Rate for Payer: Cash Price |
$1,918.75
|
| Rate for Payer: Cigna Commercial |
$3,185.12
|
| Rate for Payer: First Health Commercial |
$3,645.62
|
| Rate for Payer: Humana Commercial |
$3,261.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,146.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,338.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,647.88
|
| Rate for Payer: PHCS Commercial |
$3,684.00
|
| Rate for Payer: United Healthcare All Payer |
$3,377.00
|
|
|
TRACH PERC KIT BLUE RHINO SZ 6
|
Facility
|
OP
|
$3,837.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,151.25 |
| Max. Negotiated Rate |
$3,684.00 |
| Rate for Payer: Aetna Commercial |
$2,954.88
|
| Rate for Payer: Anthem Medicaid |
$1,319.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.25
|
| Rate for Payer: Cash Price |
$1,918.75
|
| Rate for Payer: Cigna Commercial |
$3,185.12
|
| Rate for Payer: First Health Commercial |
$3,645.62
|
| Rate for Payer: Humana Commercial |
$3,261.88
|
| Rate for Payer: Humana KY Medicaid |
$1,319.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,333.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,146.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,346.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,338.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,647.88
|
| Rate for Payer: PHCS Commercial |
$3,684.00
|
| Rate for Payer: United Healthcare All Payer |
$3,377.00
|
|
|
TRACH PERC KIT BLUE RHINO SZ 8
|
Facility
|
IP
|
$3,837.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,151.25 |
| Max. Negotiated Rate |
$3,684.00 |
| Rate for Payer: Aetna Commercial |
$2,954.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.25
|
| Rate for Payer: Cash Price |
$1,918.75
|
| Rate for Payer: Cigna Commercial |
$3,185.12
|
| Rate for Payer: First Health Commercial |
$3,645.62
|
| Rate for Payer: Humana Commercial |
$3,261.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,146.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,338.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,647.88
|
| Rate for Payer: PHCS Commercial |
$3,684.00
|
| Rate for Payer: United Healthcare All Payer |
$3,377.00
|
|
|
TRACH PERC KIT BLUE RHINO SZ 8
|
Facility
|
OP
|
$3,837.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,151.25 |
| Max. Negotiated Rate |
$3,684.00 |
| Rate for Payer: Aetna Commercial |
$2,954.88
|
| Rate for Payer: Anthem Medicaid |
$1,319.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.25
|
| Rate for Payer: Cash Price |
$1,918.75
|
| Rate for Payer: Cigna Commercial |
$3,185.12
|
| Rate for Payer: First Health Commercial |
$3,645.62
|
| Rate for Payer: Humana Commercial |
$3,261.88
|
| Rate for Payer: Humana KY Medicaid |
$1,319.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,333.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,146.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,346.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,338.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,647.88
|
| Rate for Payer: PHCS Commercial |
$3,684.00
|
| Rate for Payer: United Healthcare All Payer |
$3,377.00
|
|
|
TRACRIUM (ATRACURIU 100MG/10ML
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
NDC 71288070211
|
| Hospital Charge Code |
25003530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
TRACRIUM (ATRACURIU 100MG/10ML
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
NDC 71288070211
|
| Hospital Charge Code |
25003530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$42.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$42.30
|
| Rate for Payer: Kentucky WC Medicaid |
$42.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
TRADJENTA 5MG TABLET
|
Facility
|
IP
|
$34.50
|
|
|
Service Code
|
NDC 597014061
|
| Hospital Charge Code |
25003531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.35 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$26.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.91
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Cigna Commercial |
$28.64
|
| Rate for Payer: First Health Commercial |
$32.77
|
| Rate for Payer: Humana Commercial |
$29.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.36
|
| Rate for Payer: Ohio Health Group HMO |
$25.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.80
|
| Rate for Payer: PHCS Commercial |
$33.12
|
| Rate for Payer: United Healthcare All Payer |
$30.36
|
|
|
TRADJENTA 5MG TABLET
|
Facility
|
OP
|
$34.50
|
|
|
Service Code
|
NDC 597014061
|
| Hospital Charge Code |
25003531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.35 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$26.57
|
| Rate for Payer: Anthem Medicaid |
$11.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.91
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Cigna Commercial |
$28.64
|
| Rate for Payer: First Health Commercial |
$32.77
|
| Rate for Payer: Humana Commercial |
$29.32
|
| Rate for Payer: Humana KY Medicaid |
$11.86
|
| Rate for Payer: Kentucky WC Medicaid |
$11.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.36
|
| Rate for Payer: Ohio Health Group HMO |
$25.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.80
|
| Rate for Payer: PHCS Commercial |
$33.12
|
| Rate for Payer: United Healthcare All Payer |
$30.36
|
|
|
TRAILBLAZER 0.014
|
Facility
|
IP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
|
TRAILBLAZER 0.014
|
Facility
|
OP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem Medicaid |
$590.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Humana KY Medicaid |
$590.82
|
| Rate for Payer: Kentucky WC Medicaid |
$596.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$602.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
|
TRAILBLAZER 0.014 ANGLED
|
Facility
|
OP
|
$2,048.60
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$614.58 |
| Max. Negotiated Rate |
$1,966.66 |
| Rate for Payer: Aetna Commercial |
$1,577.42
|
| Rate for Payer: Anthem Medicaid |
$704.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,597.91
|
| Rate for Payer: Cash Price |
$1,024.30
|
| Rate for Payer: Cigna Commercial |
$1,700.34
|
| Rate for Payer: First Health Commercial |
$1,946.17
|
| Rate for Payer: Humana Commercial |
$1,741.31
|
| Rate for Payer: Humana KY Medicaid |
$704.51
|
| Rate for Payer: Kentucky WC Medicaid |
$711.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,679.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,511.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$614.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$718.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,802.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,536.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,638.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,782.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,413.53
|
| Rate for Payer: PHCS Commercial |
$1,966.66
|
| Rate for Payer: United Healthcare All Payer |
$1,802.77
|
|
|
TRAILBLAZER 0.014 ANGLED
|
Facility
|
IP
|
$2,048.60
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$614.58 |
| Max. Negotiated Rate |
$1,966.66 |
| Rate for Payer: Aetna Commercial |
$1,577.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,597.91
|
| Rate for Payer: Cash Price |
$1,024.30
|
| Rate for Payer: Cigna Commercial |
$1,700.34
|
| Rate for Payer: First Health Commercial |
$1,946.17
|
| Rate for Payer: Humana Commercial |
$1,741.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,679.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,511.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$614.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,802.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,536.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,638.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,782.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,413.53
|
| Rate for Payer: PHCS Commercial |
$1,966.66
|
| Rate for Payer: United Healthcare All Payer |
$1,802.77
|
|
|
TRAILBLAZER 0.018
|
Facility
|
IP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.10 |
| Max. Negotiated Rate |
$1,849.92 |
| Rate for Payer: Aetna Commercial |
$1,483.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.06
|
| Rate for Payer: Cash Price |
$963.50
|
| Rate for Payer: Cigna Commercial |
$1,599.41
|
| Rate for Payer: First Health Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,695.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,541.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,676.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,329.63
|
| Rate for Payer: PHCS Commercial |
$1,849.92
|
| Rate for Payer: United Healthcare All Payer |
$1,695.76
|
|
|
TRAILBLAZER 0.018
|
Facility
|
OP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.10 |
| Max. Negotiated Rate |
$1,849.92 |
| Rate for Payer: Aetna Commercial |
$1,483.79
|
| Rate for Payer: Anthem Medicaid |
$662.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.06
|
| Rate for Payer: Cash Price |
$963.50
|
| Rate for Payer: Cigna Commercial |
$1,599.41
|
| Rate for Payer: First Health Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial |
$1,637.95
|
| Rate for Payer: Humana KY Medicaid |
$662.70
|
| Rate for Payer: Kentucky WC Medicaid |
$669.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$675.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,695.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,541.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,676.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,329.63
|
| Rate for Payer: PHCS Commercial |
$1,849.92
|
| Rate for Payer: United Healthcare All Payer |
$1,695.76
|
|
|
TRAILBLAZER 0.035
|
Facility
|
OP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem Medicaid |
$590.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Humana KY Medicaid |
$590.82
|
| Rate for Payer: Kentucky WC Medicaid |
$596.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$602.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
|
TRAILBLAZER 0.035
|
Facility
|
IP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
