|
TRETINOIN 0.1%
|
Professional
|
Both
|
$99.00
|
|
| Hospital Charge Code |
22200158
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Multiplan PHCS |
$59.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$69.30
|
| Rate for Payer: UHCCP Medicaid |
$34.65
|
|
|
TRETINOIN 0.1%
|
Facility
|
IP
|
$99.00
|
|
| Hospital Charge Code |
22200158
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Aetna Commercial |
$76.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.22
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$82.17
|
| Rate for Payer: First Health Commercial |
$94.05
|
| Rate for Payer: Humana Commercial |
$84.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.12
|
| Rate for Payer: Ohio Health Group HMO |
$74.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.31
|
| Rate for Payer: PHCS Commercial |
$95.04
|
| Rate for Payer: United Healthcare All Payer |
$87.12
|
|
|
TRETINOIN 0.1%
|
Facility
|
OP
|
$99.00
|
|
| Hospital Charge Code |
22200158
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Aetna Commercial |
$76.23
|
| Rate for Payer: Anthem Medicaid |
$34.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.22
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$82.17
|
| Rate for Payer: First Health Commercial |
$94.05
|
| Rate for Payer: Humana Commercial |
$84.15
|
| Rate for Payer: Humana KY Medicaid |
$34.05
|
| Rate for Payer: Kentucky WC Medicaid |
$34.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.12
|
| Rate for Payer: Ohio Health Group HMO |
$74.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.31
|
| Rate for Payer: PHCS Commercial |
$95.04
|
| Rate for Payer: United Healthcare All Payer |
$87.12
|
|
|
TRIAD HYDROPHYLIC PASTE 170gm
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 11701003132
|
| Hospital Charge Code |
25004456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cigna Commercial |
$3.32
|
| Rate for Payer: First Health Commercial |
$3.80
|
| Rate for Payer: Humana Commercial |
$3.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.52
|
| Rate for Payer: Ohio Health Group HMO |
$3.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.76
|
| Rate for Payer: PHCS Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Payer |
$3.52
|
|
|
TRIAD HYDROPHYLIC PASTE 170gm
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 11701003132
|
| Hospital Charge Code |
25004456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Anthem Medicaid |
$1.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cigna Commercial |
$3.32
|
| Rate for Payer: First Health Commercial |
$3.80
|
| Rate for Payer: Humana Commercial |
$3.40
|
| Rate for Payer: Humana KY Medicaid |
$1.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.52
|
| Rate for Payer: Ohio Health Group HMO |
$3.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.76
|
| Rate for Payer: PHCS Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Payer |
$3.52
|
|
|
TRIAD HYDROPHYLIC PASTE 71gm
|
Facility
|
IP
|
$5.15
|
|
|
Service Code
|
NDC 11701003133
|
| Hospital Charge Code |
25004438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$3.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.02
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.27
|
| Rate for Payer: First Health Commercial |
$4.89
|
| Rate for Payer: Humana Commercial |
$4.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.53
|
| Rate for Payer: Ohio Health Group HMO |
$3.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.55
|
| Rate for Payer: PHCS Commercial |
$4.94
|
| Rate for Payer: United Healthcare All Payer |
$4.53
|
|
|
TRIAD HYDROPHYLIC PASTE 71gm
|
Facility
|
OP
|
$5.15
|
|
|
Service Code
|
NDC 11701003133
|
| Hospital Charge Code |
25004438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$3.97
|
| Rate for Payer: Anthem Medicaid |
$1.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.02
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.27
|
| Rate for Payer: First Health Commercial |
$4.89
|
| Rate for Payer: Humana Commercial |
$4.38
|
| Rate for Payer: Humana KY Medicaid |
$1.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.53
|
| Rate for Payer: Ohio Health Group HMO |
$3.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.55
|
| Rate for Payer: PHCS Commercial |
$4.94
|
| Rate for Payer: United Healthcare All Payer |
$4.53
|
|
|
TRIAL ANTR STABBRG TRL 10X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 10X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 12X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 12X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 14X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 14X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 16X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 16X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 18X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 18X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 20X79
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 20X79
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 20X83
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL ANTR STABBRG TRL 20X83
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
TRIAL LINER DISP 36ID 54OD
|
Facility
|
IP
|
$766.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.95 |
| Max. Negotiated Rate |
$735.84 |
| Rate for Payer: Aetna Commercial |
$590.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$597.87
|
| Rate for Payer: Cash Price |
$383.25
|
| Rate for Payer: Cigna Commercial |
$636.20
|
| Rate for Payer: First Health Commercial |
$728.17
|
| Rate for Payer: Humana Commercial |
$651.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$628.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$565.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$674.52
|
| Rate for Payer: Ohio Health Group HMO |
$574.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$613.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$666.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$528.88
|
| Rate for Payer: PHCS Commercial |
$735.84
|
| Rate for Payer: United Healthcare All Payer |
$674.52
|
|
|
TRIAL LINER DISP 36ID 54OD
|
Facility
|
OP
|
$766.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.95 |
| Max. Negotiated Rate |
$735.84 |
| Rate for Payer: Aetna Commercial |
$590.21
|
| Rate for Payer: Anthem Medicaid |
$263.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$597.87
|
| Rate for Payer: Cash Price |
$383.25
|
| Rate for Payer: Cigna Commercial |
$636.20
|
| Rate for Payer: First Health Commercial |
$728.17
|
| Rate for Payer: Humana Commercial |
$651.52
|
| Rate for Payer: Humana KY Medicaid |
$263.60
|
| Rate for Payer: Kentucky WC Medicaid |
$266.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$628.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$565.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$268.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$674.52
|
| Rate for Payer: Ohio Health Group HMO |
$574.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$613.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$666.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$528.88
|
| Rate for Payer: PHCS Commercial |
$735.84
|
| Rate for Payer: United Healthcare All Payer |
$674.52
|
|
|
TRIAL LINER DISP 36 IDX60 OD
|
Facility
|
IP
|
$1,579.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$473.89 |
| Max. Negotiated Rate |
$1,516.44 |
| Rate for Payer: Aetna Commercial |
$1,216.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,232.10
|
| Rate for Payer: Cash Price |
$789.81
|
| Rate for Payer: Cigna Commercial |
$1,311.08
|
| Rate for Payer: First Health Commercial |
$1,500.64
|
| Rate for Payer: Humana Commercial |
$1,342.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,295.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,165.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$473.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,390.07
|
| Rate for Payer: Ohio Health Group HMO |
$1,184.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,263.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,374.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,089.94
|
| Rate for Payer: PHCS Commercial |
$1,516.44
|
| Rate for Payer: United Healthcare All Payer |
$1,390.07
|
|
|
TRIAL LINER DISP 36 IDX60 OD
|
Facility
|
OP
|
$1,579.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$473.89 |
| Max. Negotiated Rate |
$1,516.44 |
| Rate for Payer: Aetna Commercial |
$1,216.31
|
| Rate for Payer: Anthem Medicaid |
$543.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,232.10
|
| Rate for Payer: Cash Price |
$789.81
|
| Rate for Payer: Cigna Commercial |
$1,311.08
|
| Rate for Payer: First Health Commercial |
$1,500.64
|
| Rate for Payer: Humana Commercial |
$1,342.68
|
| Rate for Payer: Humana KY Medicaid |
$543.23
|
| Rate for Payer: Kentucky WC Medicaid |
$548.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,295.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,165.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$473.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$554.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,390.07
|
| Rate for Payer: Ohio Health Group HMO |
$1,184.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,263.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,374.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,089.94
|
| Rate for Payer: PHCS Commercial |
$1,516.44
|
| Rate for Payer: United Healthcare All Payer |
$1,390.07
|
|
