|
TRILAFON (PERPHENAZIN 2MG/1TAB
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 591410101
|
| Hospital Charge Code |
25001596
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
TRILAFON (PERPHENAZIN 2MG/1TAB
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 591410101
|
| Hospital Charge Code |
25001596
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
TRILAFON (PERPHENAZIN 4MG/1TAB
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 64980029101
|
| Hospital Charge Code |
25001597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
TRILAFON (PERPHENAZIN 4MG/1TAB
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 64980029101
|
| Hospital Charge Code |
25001597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
TRILEPTAL 300 MG 5ML ORAL SUSP
|
Facility
|
OP
|
$24.27
|
|
|
Service Code
|
NDC 68094012362
|
| Hospital Charge Code |
25001598
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$23.30 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: Anthem Medicaid |
$8.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.93
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Cigna Commercial |
$20.14
|
| Rate for Payer: First Health Commercial |
$23.06
|
| Rate for Payer: Humana Commercial |
$20.63
|
| Rate for Payer: Humana KY Medicaid |
$8.35
|
| Rate for Payer: Kentucky WC Medicaid |
$8.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.36
|
| Rate for Payer: Ohio Health Group HMO |
$18.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.52
|
| Rate for Payer: PHCS Commercial |
$23.30
|
| Rate for Payer: United Healthcare All Payer |
$21.36
|
|
|
TRILEPTAL 300 MG 5ML ORAL SUSP
|
Facility
|
IP
|
$24.27
|
|
|
Service Code
|
NDC 68094012362
|
| Hospital Charge Code |
25001598
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$23.30 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.93
|
| Rate for Payer: Cash Price |
$12.13
|
| Rate for Payer: Cigna Commercial |
$20.14
|
| Rate for Payer: First Health Commercial |
$23.06
|
| Rate for Payer: Humana Commercial |
$20.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.36
|
| Rate for Payer: Ohio Health Group HMO |
$18.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.52
|
| Rate for Payer: PHCS Commercial |
$23.30
|
| Rate for Payer: United Healthcare All Payer |
$21.36
|
|
|
TRILEPTAL(OXCARBAZEPINE)150MGT
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 68462013701
|
| Hospital Charge Code |
25001600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TRILEPTAL(OXCARBAZEPINE)150MGT
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 68462013701
|
| Hospital Charge Code |
25001600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TRI LM/RL TIB AUG SZ 1 10MM
|
Facility
|
IP
|
$7,537.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.90 |
| Max. Negotiated Rate |
$7,236.19 |
| Rate for Payer: Aetna Commercial |
$5,804.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,879.41
|
| Rate for Payer: Cash Price |
$3,768.85
|
| Rate for Payer: Cigna Commercial |
$6,256.29
|
| Rate for Payer: First Health Commercial |
$7,160.82
|
| Rate for Payer: Humana Commercial |
$6,407.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,180.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,562.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,261.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,633.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,653.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,507.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$979.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,336.69
|
| Rate for Payer: PHCS Commercial |
$7,236.19
|
| Rate for Payer: United Healthcare All Payer |
$6,633.18
|
|
|
TRI LM/RL TIB AUG SZ 1 10MM
|
Facility
|
OP
|
$7,537.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.90 |
| Max. Negotiated Rate |
$7,236.19 |
| Rate for Payer: Aetna Commercial |
$5,804.03
|
| Rate for Payer: Anthem Medicaid |
$2,592.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,879.41
|
| Rate for Payer: Cash Price |
$3,768.85
|
| Rate for Payer: Cigna Commercial |
$6,256.29
|
| Rate for Payer: First Health Commercial |
$7,160.82
|
| Rate for Payer: Humana Commercial |
$6,407.04
|
| Rate for Payer: Humana KY Medicaid |
$2,592.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,618.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,180.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,562.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,261.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,644.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,633.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,653.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,507.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$979.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,336.69
|
| Rate for Payer: PHCS Commercial |
$7,236.19
|
| Rate for Payer: United Healthcare All Payer |
$6,633.18
|
|
|
TRI LM/RL TIB AUG SZ 1 5MM
|
Facility
|
IP
|
$6,884.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.98 |
| Max. Negotiated Rate |
$6,609.12 |
| Rate for Payer: Aetna Commercial |
$5,301.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,369.91
|
| Rate for Payer: Cash Price |
$3,442.25
|
| Rate for Payer: Cigna Commercial |
$5,714.14
|
| Rate for Payer: First Health Commercial |
$6,540.28
|
| Rate for Payer: Humana Commercial |
$5,851.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,645.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,080.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,065.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,058.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,163.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,376.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$894.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.20
|
| Rate for Payer: PHCS Commercial |
$6,609.12
|
| Rate for Payer: United Healthcare All Payer |
$6,058.36
|
|
|
TRI LM/RL TIB AUG SZ 1 5MM
|
Facility
|
OP
|
$6,884.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.98 |
| Max. Negotiated Rate |
$6,609.12 |
| Rate for Payer: Aetna Commercial |
$5,301.06
|
| Rate for Payer: Anthem Medicaid |
$2,367.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,369.91
|
| Rate for Payer: Cash Price |
$3,442.25
|
| Rate for Payer: Cigna Commercial |
$5,714.14
|
| Rate for Payer: First Health Commercial |
$6,540.28
|
| Rate for Payer: Humana Commercial |
$5,851.82
|
| Rate for Payer: Humana KY Medicaid |
$2,367.58
|
| Rate for Payer: Kentucky WC Medicaid |
$2,391.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,645.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,080.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,065.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,415.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,058.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,163.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,376.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$894.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.20
|
| Rate for Payer: PHCS Commercial |
$6,609.12
|
| Rate for Payer: United Healthcare All Payer |
$6,058.36
|
|
|
TRI LM/RL TIB AUG SZ 2 10MM
|
Facility
|
IP
|
$7,222.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$938.95 |
| Max. Negotiated Rate |
$6,933.79 |
| Rate for Payer: Aetna Commercial |
$5,561.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,633.71
|
| Rate for Payer: Cash Price |
$3,611.35
|
| Rate for Payer: Cigna Commercial |
$5,994.84
|
| Rate for Payer: First Health Commercial |
$6,861.56
|
| Rate for Payer: Humana Commercial |
$6,139.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,922.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,330.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,166.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,355.98
|
| Rate for Payer: Ohio Health Group HMO |
$5,417.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,444.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$938.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,239.04
|
| Rate for Payer: PHCS Commercial |
$6,933.79
|
| Rate for Payer: United Healthcare All Payer |
$6,355.98
|
|
|
TRI LM/RL TIB AUG SZ 2 10MM
|
Facility
|
OP
|
$7,222.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$938.95 |
| Max. Negotiated Rate |
$6,933.79 |
| Rate for Payer: Aetna Commercial |
$5,561.48
|
| Rate for Payer: Anthem Medicaid |
$2,483.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,633.71
|
| Rate for Payer: Cash Price |
$3,611.35
|
| Rate for Payer: Cigna Commercial |
$5,994.84
|
| Rate for Payer: First Health Commercial |
$6,861.56
|
| Rate for Payer: Humana Commercial |
$6,139.30
|
| Rate for Payer: Humana KY Medicaid |
$2,483.89
|
| Rate for Payer: Kentucky WC Medicaid |
$2,509.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,922.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,330.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,166.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,533.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,355.98
|
| Rate for Payer: Ohio Health Group HMO |
$5,417.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,444.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$938.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,239.04
|
| Rate for Payer: PHCS Commercial |
$6,933.79
|
| Rate for Payer: United Healthcare All Payer |
$6,355.98
|
|
|
TRI LM/RL TIB AUG SZ 2 5MM
|
Facility
|
OP
|
$7,805.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.68 |
| Max. Negotiated Rate |
$7,493.03 |
| Rate for Payer: Aetna Commercial |
$6,010.03
|
| Rate for Payer: Anthem Medicaid |
$2,684.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,088.09
|
| Rate for Payer: Cash Price |
$3,902.62
|
| Rate for Payer: Cigna Commercial |
$6,478.35
|
| Rate for Payer: First Health Commercial |
$7,414.98
|
| Rate for Payer: Humana Commercial |
$6,634.45
|
| Rate for Payer: Humana KY Medicaid |
$2,684.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,711.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,400.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,760.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,738.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.61
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,561.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,014.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,419.62
|
| Rate for Payer: PHCS Commercial |
$7,493.03
|
| Rate for Payer: United Healthcare All Payer |
$6,868.61
|
|
|
TRI LM/RL TIB AUG SZ 2 5MM
|
Facility
|
IP
|
$7,805.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.68 |
| Max. Negotiated Rate |
$7,493.03 |
| Rate for Payer: Aetna Commercial |
$6,010.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,088.09
|
| Rate for Payer: Cash Price |
$3,902.62
|
| Rate for Payer: Cigna Commercial |
$6,478.35
|
| Rate for Payer: First Health Commercial |
$7,414.98
|
| Rate for Payer: Humana Commercial |
$6,634.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,400.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,760.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.61
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,561.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,014.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,419.62
|
| Rate for Payer: PHCS Commercial |
$7,493.03
|
| Rate for Payer: United Healthcare All Payer |
$6,868.61
|
|
|
TRI LM/RL TIB AUG SZ 3 10MM
|
Facility
|
OP
|
$7,051.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$916.70 |
| Max. Negotiated Rate |
$6,769.46 |
| Rate for Payer: Aetna Commercial |
$5,429.67
|
| Rate for Payer: Anthem Medicaid |
$2,425.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,500.19
|
| Rate for Payer: Cash Price |
$3,525.76
|
| Rate for Payer: Cigna Commercial |
$5,852.76
|
| Rate for Payer: First Health Commercial |
$6,698.94
|
| Rate for Payer: Humana Commercial |
$5,993.79
|
| Rate for Payer: Humana KY Medicaid |
$2,425.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,449.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,782.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,204.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,115.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,473.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,205.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,288.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,410.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$916.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,185.97
|
| Rate for Payer: PHCS Commercial |
$6,769.46
|
| Rate for Payer: United Healthcare All Payer |
$6,205.34
|
|
|
TRI LM/RL TIB AUG SZ 3 10MM
|
Facility
|
IP
|
$7,051.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$916.70 |
| Max. Negotiated Rate |
$6,769.46 |
| Rate for Payer: Aetna Commercial |
$5,429.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,500.19
|
| Rate for Payer: Cash Price |
$3,525.76
|
| Rate for Payer: Cigna Commercial |
$5,852.76
|
| Rate for Payer: First Health Commercial |
$6,698.94
|
| Rate for Payer: Humana Commercial |
$5,993.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,782.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,204.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,115.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,205.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,288.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,410.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$916.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,185.97
|
| Rate for Payer: PHCS Commercial |
$6,769.46
|
| Rate for Payer: United Healthcare All Payer |
$6,205.34
|
|
|
TRI LM/RL TIB AUG SZ 3 5MM
|
Facility
|
IP
|
$7,805.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.68 |
| Max. Negotiated Rate |
$7,493.03 |
| Rate for Payer: Aetna Commercial |
$6,010.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,088.09
|
| Rate for Payer: Cash Price |
$3,902.62
|
| Rate for Payer: Cigna Commercial |
$6,478.35
|
| Rate for Payer: First Health Commercial |
$7,414.98
|
| Rate for Payer: Humana Commercial |
$6,634.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,400.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,760.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.61
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,561.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,014.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,419.62
|
| Rate for Payer: PHCS Commercial |
$7,493.03
|
| Rate for Payer: United Healthcare All Payer |
$6,868.61
|
|
|
TRI LM/RL TIB AUG SZ 3 5MM
|
Facility
|
OP
|
$7,805.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.68 |
| Max. Negotiated Rate |
$7,493.03 |
| Rate for Payer: Aetna Commercial |
$6,010.03
|
| Rate for Payer: Anthem Medicaid |
$2,684.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,088.09
|
| Rate for Payer: Cash Price |
$3,902.62
|
| Rate for Payer: Cigna Commercial |
$6,478.35
|
| Rate for Payer: First Health Commercial |
$7,414.98
|
| Rate for Payer: Humana Commercial |
$6,634.45
|
| Rate for Payer: Humana KY Medicaid |
$2,684.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,711.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,400.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,760.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,738.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.61
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,561.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,014.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,419.62
|
| Rate for Payer: PHCS Commercial |
$7,493.03
|
| Rate for Payer: United Healthcare All Payer |
$6,868.61
|
|
|
TRI LM/RL TIB AUG SZ 4 10MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI LM/RL TIB AUG SZ 4 10MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI LM/RL TIB AUG SZ 4 5MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI LM/RL TIB AUG SZ 4 5MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI LM/RL TIB AUG SZ 5 10MM
|
Facility
|
OP
|
$7,690.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.74 |
| Max. Negotiated Rate |
$7,382.66 |
| Rate for Payer: Aetna Commercial |
$5,921.51
|
| Rate for Payer: Anthem Medicaid |
$2,644.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,998.41
|
| Rate for Payer: Cash Price |
$3,845.14
|
| Rate for Payer: Cigna Commercial |
$6,382.92
|
| Rate for Payer: First Health Commercial |
$7,305.76
|
| Rate for Payer: Humana Commercial |
$6,536.73
|
| Rate for Payer: Humana KY Medicaid |
$2,644.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,671.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,306.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,675.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,307.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,697.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,767.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,767.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,538.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$999.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,383.98
|
| Rate for Payer: PHCS Commercial |
$7,382.66
|
| Rate for Payer: United Healthcare All Payer |
$6,767.44
|
|
