|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
761T2629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.25
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
76102629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
761T2629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$94.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$94.57
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$96.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.25
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
76102632
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
761P2632
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna Commercial |
$49.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.45
|
| Rate for Payer: Anthem Medicaid |
$20.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$75.04
|
| Rate for Payer: Healthspan PPO |
$66.38
|
| Rate for Payer: Humana Medicaid |
$20.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.18
|
| Rate for Payer: Molina Healthcare Passport |
$20.76
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$17.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.97
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
761P2629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna Commercial |
$49.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.45
|
| Rate for Payer: Anthem Medicaid |
$20.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$75.04
|
| Rate for Payer: Healthspan PPO |
$66.38
|
| Rate for Payer: Humana Medicaid |
$20.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.18
|
| Rate for Payer: Molina Healthcare Passport |
$20.76
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$17.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.97
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
76102629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
76102632
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
761T2632
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$94.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$94.57
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$96.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.25
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
761T2632
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.25
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
76102632
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$49.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.45
|
| Rate for Payer: Anthem Medicaid |
$20.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$75.04
|
| Rate for Payer: Healthspan PPO |
$66.38
|
| Rate for Payer: Humana Medicaid |
$20.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.18
|
| Rate for Payer: Molina Healthcare Passport |
$20.76
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$17.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.97
|
|
|
TRIM SKIN LESIONS 2 TO 4
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 11056
|
| Hospital Charge Code |
76102629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$49.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.45
|
| Rate for Payer: Anthem Medicaid |
$20.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$75.04
|
| Rate for Payer: Healthspan PPO |
$66.38
|
| Rate for Payer: Humana Medicaid |
$20.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.18
|
| Rate for Payer: Molina Healthcare Passport |
$20.76
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$17.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.97
|
|
|
TRINSICON CAPSULE (COMBIN 1CAP
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 51991063501
|
| Hospital Charge Code |
25001603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
TRINSICON CAPSULE (COMBIN 1CAP
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 51991063501
|
| Hospital Charge Code |
25001603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
TRIOSTAT 10MCG/ML VIAL
|
Facility
|
OP
|
$1,003.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.39 |
| Max. Negotiated Rate |
$962.88 |
| Rate for Payer: Aetna Commercial |
$772.31
|
| Rate for Payer: Anthem Medicaid |
$344.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$782.34
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cigna Commercial |
$832.49
|
| Rate for Payer: First Health Commercial |
$952.85
|
| Rate for Payer: Humana Commercial |
$852.55
|
| Rate for Payer: Humana KY Medicaid |
$344.93
|
| Rate for Payer: Kentucky WC Medicaid |
$348.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$822.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$740.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$351.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$882.64
|
| Rate for Payer: Ohio Health Group HMO |
$752.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.93
|
| Rate for Payer: PHCS Commercial |
$962.88
|
| Rate for Payer: United Healthcare All Payer |
$882.64
|
|
|
TRIOSTAT 10MCG/ML VIAL
|
Facility
|
IP
|
$1,003.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.39 |
| Max. Negotiated Rate |
$962.88 |
| Rate for Payer: Aetna Commercial |
$772.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$782.34
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cigna Commercial |
$832.49
|
| Rate for Payer: First Health Commercial |
$952.85
|
| Rate for Payer: Humana Commercial |
$852.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$822.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$740.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$882.64
|
| Rate for Payer: Ohio Health Group HMO |
$752.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.93
|
| Rate for Payer: PHCS Commercial |
$962.88
|
| Rate for Payer: United Healthcare All Payer |
$882.64
|
|
|
TRIO SUBLAT/SUBLIME & SRS/IPL
|
Professional
|
Both
|
$950.00
|
|
| Hospital Charge Code |
22200405
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$332.50 |
| Max. Negotiated Rate |
$950.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$950.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Multiplan PHCS |
$570.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$665.00
|
| Rate for Payer: UHCCP Medicaid |
$332.50
|
|
|
TRIPLE ANTIBOTIC OINT PKTS
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 45802014300
|
| Hospital Charge Code |
25003546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Anthem Medicaid |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.12
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna Commercial |
$0.12
|
| Rate for Payer: First Health Commercial |
$0.14
|
| Rate for Payer: Humana Commercial |
$0.13
|
| Rate for Payer: Humana KY Medicaid |
$0.05
|
| Rate for Payer: Kentucky WC Medicaid |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.13
|
| Rate for Payer: Ohio Health Group HMO |
$0.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.05
|
| Rate for Payer: PHCS Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Payer |
$0.13
|
|
|
TRIPLE ANTIBOTIC OINT PKTS
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 45802014300
|
| Hospital Charge Code |
25003546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.12
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna Commercial |
$0.12
|
| Rate for Payer: First Health Commercial |
$0.14
|
| Rate for Payer: Humana Commercial |
$0.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.13
|
| Rate for Payer: Ohio Health Group HMO |
$0.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.05
|
| Rate for Payer: PHCS Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Payer |
$0.13
|
|
|
TRIPLE LUMEN EXTRACT BALLOON 1
|
Facility
|
OP
|
$1,834.26
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.45 |
| Max. Negotiated Rate |
$1,760.89 |
| Rate for Payer: Aetna Commercial |
$1,412.38
|
| Rate for Payer: Anthem Medicaid |
$630.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.72
|
| Rate for Payer: Cash Price |
$917.13
|
| Rate for Payer: Cigna Commercial |
$1,522.44
|
| Rate for Payer: First Health Commercial |
$1,742.55
|
| Rate for Payer: Humana Commercial |
$1,559.12
|
| Rate for Payer: Humana KY Medicaid |
$630.80
|
| Rate for Payer: Kentucky WC Medicaid |
$637.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$643.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$366.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$238.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$568.62
|
| Rate for Payer: PHCS Commercial |
$1,760.89
|
| Rate for Payer: United Healthcare All Payer |
$1,614.15
|
|
|
TRIPLE LUMEN EXTRACT BALLOON 1
|
Facility
|
IP
|
$1,834.26
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.45 |
| Max. Negotiated Rate |
$1,760.89 |
| Rate for Payer: Aetna Commercial |
$1,412.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.72
|
| Rate for Payer: Cash Price |
$917.13
|
| Rate for Payer: Cigna Commercial |
$1,522.44
|
| Rate for Payer: First Health Commercial |
$1,742.55
|
| Rate for Payer: Humana Commercial |
$1,559.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$366.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$238.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$568.62
|
| Rate for Payer: PHCS Commercial |
$1,760.89
|
| Rate for Payer: United Healthcare All Payer |
$1,614.15
|
|
|
TRIPLE LUMEN EXTRACT BALLOON 2
|
Facility
|
IP
|
$1,834.26
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.45 |
| Max. Negotiated Rate |
$1,760.89 |
| Rate for Payer: Aetna Commercial |
$1,412.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.72
|
| Rate for Payer: Cash Price |
$917.13
|
| Rate for Payer: Cigna Commercial |
$1,522.44
|
| Rate for Payer: First Health Commercial |
$1,742.55
|
| Rate for Payer: Humana Commercial |
$1,559.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$366.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$238.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$568.62
|
| Rate for Payer: PHCS Commercial |
$1,760.89
|
| Rate for Payer: United Healthcare All Payer |
$1,614.15
|
|
|
TRIPLE LUMEN EXTRACT BALLOON 2
|
Facility
|
OP
|
$1,834.26
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.45 |
| Max. Negotiated Rate |
$1,760.89 |
| Rate for Payer: Aetna Commercial |
$1,412.38
|
| Rate for Payer: Anthem Medicaid |
$630.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.72
|
| Rate for Payer: Cash Price |
$917.13
|
| Rate for Payer: Cigna Commercial |
$1,522.44
|
| Rate for Payer: First Health Commercial |
$1,742.55
|
| Rate for Payer: Humana Commercial |
$1,559.12
|
| Rate for Payer: Humana KY Medicaid |
$630.80
|
| Rate for Payer: Kentucky WC Medicaid |
$637.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$643.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$366.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$238.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$568.62
|
| Rate for Payer: PHCS Commercial |
$1,760.89
|
| Rate for Payer: United Healthcare All Payer |
$1,614.15
|
|
|
TRI PRESS FIT STEM 10MM*100MM
|
Facility
|
IP
|
$8,019.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.58 |
| Max. Negotiated Rate |
$7,699.07 |
| Rate for Payer: Aetna Commercial |
$6,175.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,255.49
|
| Rate for Payer: Cash Price |
$4,009.93
|
| Rate for Payer: Cigna Commercial |
$6,656.48
|
| Rate for Payer: First Health Commercial |
$7,618.87
|
| Rate for Payer: Humana Commercial |
$6,816.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,576.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,918.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,057.48
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,603.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,042.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,486.16
|
| Rate for Payer: PHCS Commercial |
$7,699.07
|
| Rate for Payer: United Healthcare All Payer |
$7,057.48
|
|
|
TRI PRESS FIT STEM 10MM*100MM
|
Facility
|
OP
|
$8,019.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.58 |
| Max. Negotiated Rate |
$7,699.07 |
| Rate for Payer: Aetna Commercial |
$6,175.29
|
| Rate for Payer: Anthem Medicaid |
$2,758.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,255.49
|
| Rate for Payer: Cash Price |
$4,009.93
|
| Rate for Payer: Cigna Commercial |
$6,656.48
|
| Rate for Payer: First Health Commercial |
$7,618.87
|
| Rate for Payer: Humana Commercial |
$6,816.88
|
| Rate for Payer: Humana KY Medicaid |
$2,758.03
|
| Rate for Payer: Kentucky WC Medicaid |
$2,786.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,576.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,918.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,813.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,057.48
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,603.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,042.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,486.16
|
| Rate for Payer: PHCS Commercial |
$7,699.07
|
| Rate for Payer: United Healthcare All Payer |
$7,057.48
|
|
