|
TRANSVEN PACER INSERT/MANAGEM
|
Facility
|
OP
|
$11,811.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
45000230
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4,061.80 |
| Max. Negotiated Rate |
$11,338.56 |
| Rate for Payer: Aetna Commercial |
$9,094.47
|
| Rate for Payer: Anthem Medicaid |
$4,061.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,646.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,212.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,705.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,323.23
|
| Rate for Payer: Cash Price |
$5,905.50
|
| Rate for Payer: Cash Price |
$5,905.50
|
| Rate for Payer: Cigna Commercial |
$9,803.13
|
| Rate for Payer: First Health Commercial |
$11,220.45
|
| Rate for Payer: Humana Commercial |
$10,039.35
|
| Rate for Payer: Humana KY Medicaid |
$4,061.80
|
| Rate for Payer: Humana Medicare Advantage |
$7,646.84
|
| Rate for Payer: Kentucky WC Medicaid |
$4,103.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,685.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,716.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,176.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,143.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,393.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,858.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,275.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,149.59
|
| Rate for Payer: PHCS Commercial |
$11,338.56
|
| Rate for Payer: United Healthcare All Payer |
$10,393.68
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Professional
|
Both
|
$11,732.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
48100001
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$150.94 |
| Max. Negotiated Rate |
$7,039.20 |
| Rate for Payer: Aetna Commercial |
$310.95
|
| Rate for Payer: Ambetter Exchange |
$150.94
|
| Rate for Payer: Anthem Medicaid |
$191.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$150.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$181.13
|
| Rate for Payer: Cash Price |
$5,866.00
|
| Rate for Payer: Cash Price |
$5,866.00
|
| Rate for Payer: Cigna Commercial |
$283.81
|
| Rate for Payer: Healthspan PPO |
$305.73
|
| Rate for Payer: Humana Medicaid |
$191.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$255.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$150.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.75
|
| Rate for Payer: Molina Healthcare Passport |
$191.91
|
| Rate for Payer: Multiplan PHCS |
$7,039.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$196.22
|
| Rate for Payer: UHCCP Medicaid |
$4,106.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$150.94
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Facility
|
OP
|
$11,732.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
48100001
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,034.63 |
| Max. Negotiated Rate |
$11,262.72 |
| Rate for Payer: Aetna Commercial |
$9,033.64
|
| Rate for Payer: Anthem Medicaid |
$4,034.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,646.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,150.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,705.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,323.23
|
| Rate for Payer: Cash Price |
$5,866.00
|
| Rate for Payer: Cash Price |
$5,866.00
|
| Rate for Payer: Cigna Commercial |
$9,737.56
|
| Rate for Payer: First Health Commercial |
$11,145.40
|
| Rate for Payer: Humana Commercial |
$9,972.20
|
| Rate for Payer: Humana KY Medicaid |
$4,034.63
|
| Rate for Payer: Humana Medicare Advantage |
$7,646.84
|
| Rate for Payer: Kentucky WC Medicaid |
$4,075.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,620.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,658.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,176.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,115.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,324.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,799.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,385.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,206.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,095.08
|
| Rate for Payer: PHCS Commercial |
$11,262.72
|
| Rate for Payer: United Healthcare All Payer |
$10,324.16
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Facility
|
IP
|
$11,811.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
45000230
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,543.30 |
| Max. Negotiated Rate |
$11,338.56 |
| Rate for Payer: Aetna Commercial |
$9,094.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,212.58
|
| Rate for Payer: Cash Price |
$5,905.50
|
| Rate for Payer: Cigna Commercial |
$9,803.13
|
| Rate for Payer: First Health Commercial |
$11,220.45
|
| Rate for Payer: Humana Commercial |
$10,039.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,685.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,716.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,543.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,393.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,858.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,275.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,149.59
|
| Rate for Payer: PHCS Commercial |
$11,338.56
|
| Rate for Payer: United Healthcare All Payer |
$10,393.68
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Facility
|
IP
|
$11,732.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
48100001
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,519.60 |
| Max. Negotiated Rate |
$11,262.72 |
| Rate for Payer: Aetna Commercial |
$9,033.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,150.96
|
| Rate for Payer: Cash Price |
$5,866.00
|
| Rate for Payer: Cigna Commercial |
$9,737.56
|
| Rate for Payer: First Health Commercial |
$11,145.40
|
| Rate for Payer: Humana Commercial |
$9,972.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,620.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,658.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,519.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,324.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,799.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,385.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,206.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,095.08
|
| Rate for Payer: PHCS Commercial |
$11,262.72
|
| Rate for Payer: United Healthcare All Payer |
$10,324.16
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Facility
|
IP
|
$11,362.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
481T0001
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,408.60 |
| Max. Negotiated Rate |
$10,907.52 |
| Rate for Payer: Aetna Commercial |
$8,748.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,862.36
|
| Rate for Payer: Cash Price |
$5,681.00
|
| Rate for Payer: Cigna Commercial |
$9,430.46
|
| Rate for Payer: First Health Commercial |
$10,793.90
|
| Rate for Payer: Humana Commercial |
$9,657.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,316.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,385.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,408.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,998.56
|
| Rate for Payer: Ohio Health Group HMO |
$8,521.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,089.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,884.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,839.78
|
| Rate for Payer: PHCS Commercial |
$10,907.52
|
| Rate for Payer: United Healthcare All Payer |
$9,998.56
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Facility
|
OP
|
$11,362.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
481T0001
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,907.39 |
| Max. Negotiated Rate |
$10,907.52 |
| Rate for Payer: Aetna Commercial |
$8,748.74
|
| Rate for Payer: Anthem Medicaid |
$3,907.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,646.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,862.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,705.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,323.23
|
| Rate for Payer: Cash Price |
$5,681.00
|
| Rate for Payer: Cash Price |
$5,681.00
|
| Rate for Payer: Cigna Commercial |
$9,430.46
|
| Rate for Payer: First Health Commercial |
$10,793.90
|
| Rate for Payer: Humana Commercial |
$9,657.70
|
| Rate for Payer: Humana KY Medicaid |
$3,907.39
|
| Rate for Payer: Humana Medicare Advantage |
$7,646.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,947.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,316.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,385.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,176.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,985.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,998.56
|
| Rate for Payer: Ohio Health Group HMO |
$8,521.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,089.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,884.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,839.78
|
| Rate for Payer: PHCS Commercial |
$10,907.52
|
| Rate for Payer: United Healthcare All Payer |
$9,998.56
|
|
|
TRANSVEN PACER INSERT/MANAGEM
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS 33210
|
| Hospital Charge Code |
481P0001
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$129.50 |
| Max. Negotiated Rate |
$310.95 |
| Rate for Payer: Aetna Commercial |
$310.95
|
| Rate for Payer: Ambetter Exchange |
$150.94
|
| Rate for Payer: Anthem Medicaid |
$191.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$150.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$181.13
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$283.81
|
| Rate for Payer: Healthspan PPO |
$305.73
|
| Rate for Payer: Humana Medicaid |
$191.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$255.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$150.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.75
|
| Rate for Payer: Molina Healthcare Passport |
$191.91
|
| Rate for Payer: Multiplan PHCS |
$222.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$196.22
|
| Rate for Payer: UHCCP Medicaid |
$129.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$150.94
|
|
|
TRAP 4.5 CATH 5F
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
TRAP 4.5 CATH 5F
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| 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: Humana KY Medicaid |
$257.93
|
| 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 |
$225.00
|
| 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
|
|
|
TRAVATN(TRAVOPROST)2.5ML OPTH
|
Facility
|
IP
|
$11.12
|
|
|
Service Code
|
NDC 42571013027
|
| Hospital Charge Code |
25001581
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$10.68 |
| Rate for Payer: Aetna Commercial |
$8.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.67
|
| Rate for Payer: Cash Price |
$5.56
|
| Rate for Payer: Cigna Commercial |
$9.23
|
| Rate for Payer: First Health Commercial |
$10.56
|
| Rate for Payer: Humana Commercial |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.79
|
| Rate for Payer: Ohio Health Group HMO |
$8.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.67
|
| Rate for Payer: PHCS Commercial |
$10.68
|
| Rate for Payer: United Healthcare All Payer |
$9.79
|
|
|
TRAVATN(TRAVOPROST)2.5ML OPTH
|
Facility
|
OP
|
$11.12
|
|
|
Service Code
|
NDC 42571013027
|
| Hospital Charge Code |
25001581
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$10.68 |
| Rate for Payer: Aetna Commercial |
$8.56
|
| Rate for Payer: Anthem Medicaid |
$3.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.67
|
| Rate for Payer: Cash Price |
$5.56
|
| Rate for Payer: Cigna Commercial |
$9.23
|
| Rate for Payer: First Health Commercial |
$10.56
|
| Rate for Payer: Humana Commercial |
$9.45
|
| Rate for Payer: Humana KY Medicaid |
$3.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.79
|
| Rate for Payer: Ohio Health Group HMO |
$8.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.67
|
| Rate for Payer: PHCS Commercial |
$10.68
|
| Rate for Payer: United Healthcare All Payer |
$9.79
|
|
|
TRAZIMERA 10mg (150mg SDV)
|
Facility
|
OP
|
$6,600.50
|
|
|
Service Code
|
HCPCS Q5116
|
| Hospital Charge Code |
25004103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.62 |
| Max. Negotiated Rate |
$6,336.48 |
| Rate for Payer: Aetna Commercial |
$5,082.39
|
| Rate for Payer: Anthem Medicaid |
$2,269.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,148.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$40.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.64
|
| Rate for Payer: Cash Price |
$3,300.25
|
| Rate for Payer: Cash Price |
$3,300.25
|
| Rate for Payer: Cigna Commercial |
$5,478.41
|
| Rate for Payer: First Health Commercial |
$6,270.48
|
| Rate for Payer: Humana Commercial |
$5,610.43
|
| Rate for Payer: Humana KY Medicaid |
$2,269.91
|
| Rate for Payer: Humana Medicare Advantage |
$28.62
|
| Rate for Payer: Kentucky WC Medicaid |
$2,293.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,412.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,871.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,315.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,808.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,950.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,280.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,742.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,554.35
|
| Rate for Payer: PHCS Commercial |
$6,336.48
|
| Rate for Payer: United Healthcare All Payer |
$5,808.44
|
|
|
TRAZIMERA 10mg (150mg SDV)
|
Facility
|
IP
|
$6,600.50
|
|
|
Service Code
|
HCPCS Q5116
|
| Hospital Charge Code |
25004103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,980.15 |
| Max. Negotiated Rate |
$6,336.48 |
| Rate for Payer: Aetna Commercial |
$5,082.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,148.39
|
| Rate for Payer: Cash Price |
$3,300.25
|
| Rate for Payer: Cigna Commercial |
$5,478.41
|
| Rate for Payer: First Health Commercial |
$6,270.48
|
| Rate for Payer: Humana Commercial |
$5,610.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,412.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,871.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,980.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,808.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,950.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,280.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,742.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,554.35
|
| Rate for Payer: PHCS Commercial |
$6,336.48
|
| Rate for Payer: United Healthcare All Payer |
$5,808.44
|
|
|
TRAZIMERA 10mg(from 420mg MDV)
|
Facility
|
IP
|
$440.03
|
|
|
Service Code
|
HCPCS Q5116
|
| Hospital Charge Code |
25004104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.01 |
| Max. Negotiated Rate |
$422.43 |
| Rate for Payer: Aetna Commercial |
$338.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.22
|
| Rate for Payer: Cash Price |
$220.01
|
| Rate for Payer: Cigna Commercial |
$365.22
|
| Rate for Payer: First Health Commercial |
$418.03
|
| Rate for Payer: Humana Commercial |
$374.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$360.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.23
|
| Rate for Payer: Ohio Health Group HMO |
$330.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.62
|
| Rate for Payer: PHCS Commercial |
$422.43
|
| Rate for Payer: United Healthcare All Payer |
$387.23
|
|
|
TRAZIMERA 10mg(from 420mg MDV)
|
Facility
|
OP
|
$440.03
|
|
|
Service Code
|
HCPCS Q5116
|
| Hospital Charge Code |
25004104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.62 |
| Max. Negotiated Rate |
$422.43 |
| Rate for Payer: Aetna Commercial |
$338.82
|
| Rate for Payer: Anthem Medicaid |
$151.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$40.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.64
|
| Rate for Payer: Cash Price |
$220.01
|
| Rate for Payer: Cash Price |
$220.01
|
| Rate for Payer: Cigna Commercial |
$365.22
|
| Rate for Payer: First Health Commercial |
$418.03
|
| Rate for Payer: Humana Commercial |
$374.03
|
| Rate for Payer: Humana KY Medicaid |
$151.33
|
| Rate for Payer: Humana Medicare Advantage |
$28.62
|
| Rate for Payer: Kentucky WC Medicaid |
$152.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$360.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$154.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.23
|
| Rate for Payer: Ohio Health Group HMO |
$330.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.62
|
| Rate for Payer: PHCS Commercial |
$422.43
|
| Rate for Payer: United Healthcare All Payer |
$387.23
|
|
|
TREADMILL STRESS TEST
|
Facility
|
OP
|
$1,242.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200004
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$287.73 |
| Max. Negotiated Rate |
$1,192.32 |
| Rate for Payer: Aetna Commercial |
$956.34
|
| Rate for Payer: Anthem Medicaid |
$427.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$968.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$621.00
|
| Rate for Payer: Cash Price |
$621.00
|
| Rate for Payer: Cigna Commercial |
$1,030.86
|
| Rate for Payer: First Health Commercial |
$1,179.90
|
| Rate for Payer: Humana Commercial |
$1,055.70
|
| Rate for Payer: Humana KY Medicaid |
$427.12
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$431.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,018.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$916.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$435.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,092.96
|
| Rate for Payer: Ohio Health Group HMO |
$931.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$993.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,080.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$856.98
|
| Rate for Payer: PHCS Commercial |
$1,192.32
|
| Rate for Payer: United Healthcare All Payer |
$1,092.96
|
|
|
TREADMILL STRESS TEST
|
Facility
|
IP
|
$1,242.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200004
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$372.60 |
| Max. Negotiated Rate |
$1,192.32 |
| Rate for Payer: Aetna Commercial |
$956.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$968.76
|
| Rate for Payer: Cash Price |
$621.00
|
| Rate for Payer: Cigna Commercial |
$1,030.86
|
| Rate for Payer: First Health Commercial |
$1,179.90
|
| Rate for Payer: Humana Commercial |
$1,055.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,018.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$916.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$372.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,092.96
|
| Rate for Payer: Ohio Health Group HMO |
$931.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$993.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,080.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$856.98
|
| Rate for Payer: PHCS Commercial |
$1,192.32
|
| Rate for Payer: United Healthcare All Payer |
$1,092.96
|
|
|
TREANDA 25MG VIAL
|
Facility
|
OP
|
$4,049.08
|
|
|
Service Code
|
HCPCS J9033
|
| Hospital Charge Code |
25002562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$3,887.12 |
| Rate for Payer: Aetna Commercial |
$3,117.79
|
| Rate for Payer: Anthem Medicaid |
$1,392.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,158.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$2.50
|
| Rate for Payer: Cash Price |
$2,024.54
|
| Rate for Payer: Cash Price |
$2,024.54
|
| Rate for Payer: Cigna Commercial |
$3,360.74
|
| Rate for Payer: First Health Commercial |
$3,846.63
|
| Rate for Payer: Humana Commercial |
$3,441.72
|
| Rate for Payer: Humana KY Medicaid |
$1,392.48
|
| Rate for Payer: Humana Medicare Advantage |
$1.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,406.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,320.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,988.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,420.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,563.19
|
| Rate for Payer: Ohio Health Group HMO |
$3,036.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,239.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,522.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,793.87
|
| Rate for Payer: PHCS Commercial |
$3,887.12
|
| Rate for Payer: United Healthcare All Payer |
$3,563.19
|
|
|
TREANDA 25MG VIAL
|
Facility
|
IP
|
$4,049.08
|
|
|
Service Code
|
HCPCS J9033
|
| Hospital Charge Code |
25002562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,214.72 |
| Max. Negotiated Rate |
$3,887.12 |
| Rate for Payer: Aetna Commercial |
$3,117.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,158.28
|
| Rate for Payer: Cash Price |
$2,024.54
|
| Rate for Payer: Cigna Commercial |
$3,360.74
|
| Rate for Payer: First Health Commercial |
$3,846.63
|
| Rate for Payer: Humana Commercial |
$3,441.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,320.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,988.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,214.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,563.19
|
| Rate for Payer: Ohio Health Group HMO |
$3,036.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,239.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,522.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,793.87
|
| Rate for Payer: PHCS Commercial |
$3,887.12
|
| Rate for Payer: United Healthcare All Payer |
$3,563.19
|
|
|
TREASURE 12 GW 300CM
|
Facility
|
OP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
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
|
|
|
TREASURE 12 GW 300CM
|
Facility
|
IP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
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
|
|
|
TREASURE FLOPPY GW 300CM
|
Facility
|
OP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
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
|
|
|
TREASURE FLOPPY GW 300CM
|
Facility
|
IP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
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
|
|
|
TREAT ANKLE DISLOCATION
|
Facility
|
IP
|
$1,775.00
|
|
|
Service Code
|
HCPCS 27846
|
| Hospital Charge Code |
76102955
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
