|
TREAT WRIST DISLOCTE W/MANI(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 25690
|
| Hospital Charge Code |
761P0645
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.31 |
| Max. Negotiated Rate |
$724.29 |
| Rate for Payer: Aetna Commercial |
$658.26
|
| Rate for Payer: Ambetter Exchange |
$473.08
|
| Rate for Payer: Anthem Medicaid |
$300.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$473.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$473.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$567.70
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$724.29
|
| Rate for Payer: Healthspan PPO |
$596.24
|
| Rate for Payer: Humana Medicaid |
$300.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$577.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$473.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$473.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.32
|
| Rate for Payer: Molina Healthcare Passport |
$300.31
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$615.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$473.08
|
|
|
TREAT WRIST DISLOCTE W/MANIP
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 25690
|
| Hospital Charge Code |
76100645
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
TREAT WRIST DISLOCTE W/MANIP
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 25690
|
| Hospital Charge Code |
76100645
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$412.68 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
TREAT WRIST DISLOCTE W/MANIP
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 25690
|
| Hospital Charge Code |
76100645
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.31 |
| Max. Negotiated Rate |
$724.29 |
| Rate for Payer: Aetna Commercial |
$658.26
|
| Rate for Payer: Ambetter Exchange |
$473.08
|
| Rate for Payer: Anthem Medicaid |
$300.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$473.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$473.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$567.70
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$724.29
|
| Rate for Payer: Healthspan PPO |
$596.24
|
| Rate for Payer: Humana Medicaid |
$300.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$577.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$473.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$473.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.32
|
| Rate for Payer: Molina Healthcare Passport |
$300.31
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$615.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$473.08
|
|
|
TREK BALLOON OTW 1.5*15*300
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 1.5*15*300
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 2.5*12
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
TREK BALLOON OTW 2.5*12
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
TREK BALLOON OTW 2.5*15
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 2.5*15
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 3*15
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 3*15
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 3*20
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREK BALLOON OTW 3*20
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
TREMFYA 1mg (200mg SDV)
|
Facility
|
OP
|
$52,960.32
|
|
|
Service Code
|
HCPCS J1628
|
| Hospital Charge Code |
25004590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.86 |
| Max. Negotiated Rate |
$50,841.91 |
| Rate for Payer: Aetna Commercial |
$40,779.45
|
| Rate for Payer: Anthem Medicaid |
$18,213.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$74.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41,309.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$104.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$101.06
|
| Rate for Payer: Cash Price |
$26,480.16
|
| Rate for Payer: Cash Price |
$26,480.16
|
| Rate for Payer: Cigna Commercial |
$43,957.07
|
| Rate for Payer: First Health Commercial |
$50,312.30
|
| Rate for Payer: Humana Commercial |
$45,016.27
|
| Rate for Payer: Humana KY Medicaid |
$18,213.05
|
| Rate for Payer: Humana Medicare Advantage |
$74.86
|
| Rate for Payer: Kentucky WC Medicaid |
$18,398.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43,427.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39,084.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$89.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,578.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$46,605.08
|
| Rate for Payer: Ohio Health Group HMO |
$39,720.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42,368.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46,075.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36,542.62
|
| Rate for Payer: PHCS Commercial |
$50,841.91
|
| Rate for Payer: United Healthcare All Payer |
$46,605.08
|
|
|
TREMFYA 1mg (200mg SDV)
|
Facility
|
IP
|
$52,960.32
|
|
|
Service Code
|
HCPCS J1628
|
| Hospital Charge Code |
25004590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15,888.10 |
| Max. Negotiated Rate |
$50,841.91 |
| Rate for Payer: Aetna Commercial |
$40,779.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41,309.05
|
| Rate for Payer: Cash Price |
$26,480.16
|
| Rate for Payer: Cigna Commercial |
$43,957.07
|
| Rate for Payer: First Health Commercial |
$50,312.30
|
| Rate for Payer: Humana Commercial |
$45,016.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43,427.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39,084.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,888.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$46,605.08
|
| Rate for Payer: Ohio Health Group HMO |
$39,720.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42,368.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46,075.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36,542.62
|
| Rate for Payer: PHCS Commercial |
$50,841.91
|
| Rate for Payer: United Healthcare All Payer |
$46,605.08
|
|
|
TRENDA 100MG VIAL
|
Facility
|
IP
|
$16,196.31
|
|
|
Service Code
|
HCPCS J9033
|
| Hospital Charge Code |
25002563
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,858.89 |
| Max. Negotiated Rate |
$15,548.46 |
| Rate for Payer: Aetna Commercial |
$12,471.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,633.12
|
| Rate for Payer: Cash Price |
$8,098.16
|
| Rate for Payer: Cigna Commercial |
$13,442.94
|
| Rate for Payer: First Health Commercial |
$15,386.49
|
| Rate for Payer: Humana Commercial |
$13,766.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,280.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,952.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,858.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,252.75
|
| Rate for Payer: Ohio Health Group HMO |
$12,147.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,957.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,175.45
|
| Rate for Payer: PHCS Commercial |
$15,548.46
|
| Rate for Payer: United Healthcare All Payer |
$14,252.75
|
|
|
TRENDA 100MG VIAL
|
Facility
|
OP
|
$16,196.31
|
|
|
Service Code
|
HCPCS J9033
|
| Hospital Charge Code |
25002563
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$15,548.46 |
| Rate for Payer: Aetna Commercial |
$12,471.16
|
| Rate for Payer: Anthem Medicaid |
$5,569.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,633.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$2.50
|
| Rate for Payer: Cash Price |
$8,098.16
|
| Rate for Payer: Cash Price |
$8,098.16
|
| Rate for Payer: Cigna Commercial |
$13,442.94
|
| Rate for Payer: First Health Commercial |
$15,386.49
|
| Rate for Payer: Humana Commercial |
$13,766.86
|
| Rate for Payer: Humana KY Medicaid |
$5,569.91
|
| Rate for Payer: Humana Medicare Advantage |
$1.85
|
| Rate for Payer: Kentucky WC Medicaid |
$5,626.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,280.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,952.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,681.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,252.75
|
| Rate for Payer: Ohio Health Group HMO |
$12,147.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,957.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,175.45
|
| Rate for Payer: PHCS Commercial |
$15,548.46
|
| Rate for Payer: United Healthcare All Payer |
$14,252.75
|
|
|
TRENTAL(PENTOXIFYLL 400MG/1TAB
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 904544861
|
| Hospital Charge Code |
25001582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
TRENTAL(PENTOXIFYLL 400MG/1TAB
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 904544861
|
| Hospital Charge Code |
25001582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
TRESIBA U-100 INSULIN PEN
|
Facility
|
IP
|
$184.90
|
|
|
Service Code
|
NDC 169266015
|
| Hospital Charge Code |
25001583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.47 |
| Max. Negotiated Rate |
$177.50 |
| Rate for Payer: Aetna Commercial |
$142.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.22
|
| Rate for Payer: Cash Price |
$92.45
|
| Rate for Payer: Cigna Commercial |
$153.47
|
| Rate for Payer: First Health Commercial |
$175.66
|
| Rate for Payer: Humana Commercial |
$157.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.71
|
| Rate for Payer: Ohio Health Group HMO |
$138.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.58
|
| Rate for Payer: PHCS Commercial |
$177.50
|
| Rate for Payer: United Healthcare All Payer |
$162.71
|
|
|
TRESIBA U-100 INSULIN PEN
|
Facility
|
OP
|
$184.90
|
|
|
Service Code
|
NDC 169266015
|
| Hospital Charge Code |
25001583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.47 |
| Max. Negotiated Rate |
$177.50 |
| Rate for Payer: Aetna Commercial |
$142.37
|
| Rate for Payer: Anthem Medicaid |
$63.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.22
|
| Rate for Payer: Cash Price |
$92.45
|
| Rate for Payer: Cigna Commercial |
$153.47
|
| Rate for Payer: First Health Commercial |
$175.66
|
| Rate for Payer: Humana Commercial |
$157.16
|
| Rate for Payer: Humana KY Medicaid |
$63.59
|
| Rate for Payer: Kentucky WC Medicaid |
$64.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.71
|
| Rate for Payer: Ohio Health Group HMO |
$138.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.58
|
| Rate for Payer: PHCS Commercial |
$177.50
|
| Rate for Payer: United Healthcare All Payer |
$162.71
|
|
|
TRESIBA U-200 INSULIN PEN
|
Facility
|
IP
|
$621.37
|
|
|
Service Code
|
NDC 169255013
|
| Hospital Charge Code |
25001584
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.41 |
| Max. Negotiated Rate |
$596.52 |
| Rate for Payer: Aetna Commercial |
$478.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$484.67
|
| Rate for Payer: Cash Price |
$310.68
|
| Rate for Payer: Cigna Commercial |
$515.74
|
| Rate for Payer: First Health Commercial |
$590.30
|
| Rate for Payer: Humana Commercial |
$528.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$509.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$458.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$546.81
|
| Rate for Payer: Ohio Health Group HMO |
$466.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$497.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$428.75
|
| Rate for Payer: PHCS Commercial |
$596.52
|
| Rate for Payer: United Healthcare All Payer |
$546.81
|
|
|
TRESIBA U-200 INSULIN PEN
|
Facility
|
OP
|
$621.37
|
|
|
Service Code
|
NDC 169255013
|
| Hospital Charge Code |
25001584
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.41 |
| Max. Negotiated Rate |
$596.52 |
| Rate for Payer: Aetna Commercial |
$478.45
|
| Rate for Payer: Anthem Medicaid |
$213.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$484.67
|
| Rate for Payer: Cash Price |
$310.68
|
| Rate for Payer: Cigna Commercial |
$515.74
|
| Rate for Payer: First Health Commercial |
$590.30
|
| Rate for Payer: Humana Commercial |
$528.16
|
| Rate for Payer: Humana KY Medicaid |
$213.69
|
| Rate for Payer: Kentucky WC Medicaid |
$215.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$509.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$458.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$546.81
|
| Rate for Payer: Ohio Health Group HMO |
$466.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$497.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$428.75
|
| Rate for Payer: PHCS Commercial |
$596.52
|
| Rate for Payer: United Healthcare All Payer |
$546.81
|
|
|
TRETINOIN 0.05% REFISSA 20G
|
Professional
|
Both
|
$35.00
|
|
| Hospital Charge Code |
22200160
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$24.50 |
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
|
