|
ALLERGY PATCH TESTS
|
Professional
|
Both
|
$8.00
|
|
|
Service Code
|
HCPCS 95044
|
| Hospital Charge Code |
76102638
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Aetna Commercial |
$7.88
|
| Rate for Payer: Anthem Medicaid |
$5.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.00
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: Healthspan PPO |
$10.60
|
| Rate for Payer: Humana Medicaid |
$5.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$7.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$5.45
|
| Rate for Payer: Molina Healthcare Passport |
$5.34
|
| Rate for Payer: Multiplan PHCS |
$4.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.60
|
| Rate for Payer: UHCCP Medicaid |
$2.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.39
|
|
|
ALLGRFT IMPLNT KNEE W/SCOPE
|
Facility
|
OP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 29867
|
| Hospital Charge Code |
76102813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$15,933.60 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem Medicaid |
$447.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,381.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,933.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$15,364.54
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Humana KY Medicaid |
$447.07
|
| Rate for Payer: Humana Medicare Advantage |
$11,381.14
|
| Rate for Payer: Kentucky WC Medicaid |
$451.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,657.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$456.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
ALLGRFT IMPLNT KNEE W/SCOPE
|
Facility
|
IP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 29867
|
| Hospital Charge Code |
76102813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$1,248.00 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
ALLGRFT IMPLNT KNEE W/SCOPE
|
Professional
|
Both
|
$1,300.00
|
|
|
Service Code
|
HCPCS 29867
|
| Hospital Charge Code |
76102813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$2,064.10 |
| Rate for Payer: Aetna Commercial |
$1,873.76
|
| Rate for Payer: Anthem Medicaid |
$913.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,300.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$2,064.10
|
| Rate for Payer: Healthspan PPO |
$1,697.22
|
| Rate for Payer: Humana Medicaid |
$913.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,591.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$931.46
|
| Rate for Payer: Molina Healthcare Passport |
$913.20
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$922.33
|
|
|
ALLODERM MATRIX GRAFT 8X16
|
Facility
|
IP
|
$17,199.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
27000077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,235.95 |
| Max. Negotiated Rate |
$16,511.62 |
| Rate for Payer: Aetna Commercial |
$13,243.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,415.69
|
| Rate for Payer: Cash Price |
$8,599.80
|
| Rate for Payer: Cigna Commercial |
$14,275.67
|
| Rate for Payer: First Health Commercial |
$16,339.62
|
| Rate for Payer: Humana Commercial |
$14,619.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,103.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,693.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,159.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,135.65
|
| Rate for Payer: Ohio Health Group HMO |
$12,899.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,439.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,235.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,331.88
|
| Rate for Payer: PHCS Commercial |
$16,511.62
|
| Rate for Payer: United Healthcare All Payer |
$15,135.65
|
|
|
ALLODERM MATRIX GRAFT 8X16
|
Facility
|
OP
|
$17,199.60
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
27000077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,235.95 |
| Max. Negotiated Rate |
$16,511.62 |
| Rate for Payer: Aetna Commercial |
$13,243.69
|
| Rate for Payer: Anthem Medicaid |
$5,914.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,415.69
|
| Rate for Payer: Cash Price |
$8,599.80
|
| Rate for Payer: Cigna Commercial |
$14,275.67
|
| Rate for Payer: First Health Commercial |
$16,339.62
|
| Rate for Payer: Humana Commercial |
$14,619.66
|
| Rate for Payer: Humana KY Medicaid |
$5,914.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,975.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,103.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,693.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,159.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,033.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,135.65
|
| Rate for Payer: Ohio Health Group HMO |
$12,899.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,439.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,235.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,331.88
|
| Rate for Payer: PHCS Commercial |
$16,511.62
|
| Rate for Payer: United Healthcare All Payer |
$15,135.65
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$134,071.95
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$90,977.40 |
| Max. Negotiated Rate |
$134,071.95 |
| Rate for Payer: Anthem Medicaid |
$90,977.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95,765.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$134,071.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$129,283.67
|
| Rate for Payer: Humana KY Medicaid |
$90,977.40
|
| Rate for Payer: Humana Medicare Advantage |
$95,765.68
|
| Rate for Payer: Kentucky WC Medicaid |
$91,887.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114,918.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$92,796.94
|
|
|
ALLOGRAFT PLACENTA MATRIX 80MG
|
Facility
|
IP
|
$8,197.44
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,065.67 |
| Max. Negotiated Rate |
$7,869.54 |
| Rate for Payer: Aetna Commercial |
$6,312.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,394.00
|
| Rate for Payer: Cash Price |
$4,098.72
|
| Rate for Payer: Cigna Commercial |
$6,803.88
|
| Rate for Payer: First Health Commercial |
$7,787.57
|
| Rate for Payer: Humana Commercial |
$6,967.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,721.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,049.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,459.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,213.75
|
| Rate for Payer: Ohio Health Group HMO |
$6,148.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,639.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,065.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,541.21
|
| Rate for Payer: PHCS Commercial |
$7,869.54
|
| Rate for Payer: United Healthcare All Payer |
$7,213.75
|
|
|
ALLOGRAFT PLACENTA MATRIX 80MG
|
Facility
|
OP
|
$8,197.44
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,065.67 |
| Max. Negotiated Rate |
$7,869.54 |
| Rate for Payer: Aetna Commercial |
$6,312.03
|
| Rate for Payer: Anthem Medicaid |
$2,819.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,394.00
|
| Rate for Payer: Cash Price |
$4,098.72
|
| Rate for Payer: Cigna Commercial |
$6,803.88
|
| Rate for Payer: First Health Commercial |
$7,787.57
|
| Rate for Payer: Humana Commercial |
$6,967.82
|
| Rate for Payer: Humana KY Medicaid |
$2,819.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2,847.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,721.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,049.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,459.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,875.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,213.75
|
| Rate for Payer: Ohio Health Group HMO |
$6,148.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,639.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,065.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,541.21
|
| Rate for Payer: PHCS Commercial |
$7,869.54
|
| Rate for Payer: United Healthcare All Payer |
$7,213.75
|
|
|
ALLOGRAFT PLACENT MATRIX 180MG
|
Facility
|
IP
|
$13,928.80
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.74 |
| Max. Negotiated Rate |
$13,371.65 |
| Rate for Payer: Aetna Commercial |
$10,725.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,864.46
|
| Rate for Payer: Cash Price |
$6,964.40
|
| Rate for Payer: Cigna Commercial |
$11,560.90
|
| Rate for Payer: First Health Commercial |
$13,232.36
|
| Rate for Payer: Humana Commercial |
$11,839.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,421.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,279.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,178.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,257.34
|
| Rate for Payer: Ohio Health Group HMO |
$10,446.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,785.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,810.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,317.93
|
| Rate for Payer: PHCS Commercial |
$13,371.65
|
| Rate for Payer: United Healthcare All Payer |
$12,257.34
|
|
|
ALLOGRAFT PLACENT MATRIX 180MG
|
Facility
|
OP
|
$13,928.80
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.74 |
| Max. Negotiated Rate |
$13,371.65 |
| Rate for Payer: Aetna Commercial |
$10,725.18
|
| Rate for Payer: Anthem Medicaid |
$4,790.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,864.46
|
| Rate for Payer: Cash Price |
$6,964.40
|
| Rate for Payer: Cigna Commercial |
$11,560.90
|
| Rate for Payer: First Health Commercial |
$13,232.36
|
| Rate for Payer: Humana Commercial |
$11,839.48
|
| Rate for Payer: Humana KY Medicaid |
$4,790.11
|
| Rate for Payer: Kentucky WC Medicaid |
$4,838.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,421.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,279.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,178.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,886.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,257.34
|
| Rate for Payer: Ohio Health Group HMO |
$10,446.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,785.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,810.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,317.93
|
| Rate for Payer: PHCS Commercial |
$13,371.65
|
| Rate for Payer: United Healthcare All Payer |
$12,257.34
|
|
|
ALLOMEND MESH SHAPED 10*18CM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
|
|
ALLOMEND MESH SHAPED 10*18CM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
ALLOMEND MESH XL ADM 1.1
|
Facility
|
OP
|
$35,095.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,562.35 |
| Max. Negotiated Rate |
$33,691.20 |
| Rate for Payer: Aetna Commercial |
$27,023.15
|
| Rate for Payer: Anthem Medicaid |
$12,069.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,374.10
|
| Rate for Payer: Cash Price |
$17,547.50
|
| Rate for Payer: Cigna Commercial |
$29,128.85
|
| Rate for Payer: First Health Commercial |
$33,340.25
|
| Rate for Payer: Humana Commercial |
$29,830.75
|
| Rate for Payer: Humana KY Medicaid |
$12,069.17
|
| Rate for Payer: Kentucky WC Medicaid |
$12,192.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,777.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,900.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,528.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,311.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,883.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,321.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,019.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,562.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,879.45
|
| Rate for Payer: PHCS Commercial |
$33,691.20
|
| Rate for Payer: United Healthcare All Payer |
$30,883.60
|
|
|
ALLOMEND MESH XL ADM 1.1
|
Facility
|
IP
|
$35,095.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,562.35 |
| Max. Negotiated Rate |
$33,691.20 |
| Rate for Payer: Aetna Commercial |
$27,023.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,374.10
|
| Rate for Payer: Cash Price |
$17,547.50
|
| Rate for Payer: Cigna Commercial |
$29,128.85
|
| Rate for Payer: First Health Commercial |
$33,340.25
|
| Rate for Payer: Humana Commercial |
$29,830.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,777.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,900.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,528.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,883.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,321.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,019.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,562.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,879.45
|
| Rate for Payer: PHCS Commercial |
$33,691.20
|
| Rate for Payer: United Healthcare All Payer |
$30,883.60
|
|
|
ALLOPATCH PLIABLE 2*2CM
|
Facility
|
IP
|
$3,458.74
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$449.64 |
| Max. Negotiated Rate |
$3,320.39 |
| Rate for Payer: Aetna Commercial |
$2,663.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,697.82
|
| Rate for Payer: Cash Price |
$1,729.37
|
| Rate for Payer: Cigna Commercial |
$2,870.75
|
| Rate for Payer: First Health Commercial |
$3,285.80
|
| Rate for Payer: Humana Commercial |
$2,939.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,836.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,552.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,037.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,043.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,594.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$691.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$449.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.21
|
| Rate for Payer: PHCS Commercial |
$3,320.39
|
| Rate for Payer: United Healthcare All Payer |
$3,043.69
|
|
|
ALLOPATCH PLIABLE 2*2CM
|
Facility
|
OP
|
$3,458.74
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$449.64 |
| Max. Negotiated Rate |
$3,320.39 |
| Rate for Payer: Aetna Commercial |
$2,663.23
|
| Rate for Payer: Anthem Medicaid |
$1,189.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,697.82
|
| Rate for Payer: Cash Price |
$1,729.37
|
| Rate for Payer: Cigna Commercial |
$2,870.75
|
| Rate for Payer: First Health Commercial |
$3,285.80
|
| Rate for Payer: Humana Commercial |
$2,939.93
|
| Rate for Payer: Humana KY Medicaid |
$1,189.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,201.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,836.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,552.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,037.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,213.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,043.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,594.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$691.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$449.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.21
|
| Rate for Payer: PHCS Commercial |
$3,320.39
|
| Rate for Payer: United Healthcare All Payer |
$3,043.69
|
|
|
Allopurinol 1mg (500mg SDV)
|
Facility
|
IP
|
$5,650.00
|
|
|
Service Code
|
HCPCS J0206
|
| Hospital Charge Code |
25002814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$734.50 |
| Max. Negotiated Rate |
$5,424.00 |
| Rate for Payer: Aetna Commercial |
$4,350.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,407.00
|
| Rate for Payer: Cash Price |
$2,825.00
|
| Rate for Payer: Cigna Commercial |
$4,689.50
|
| Rate for Payer: First Health Commercial |
$5,367.50
|
| Rate for Payer: Humana Commercial |
$4,802.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,633.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,169.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,695.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,972.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,237.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$734.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,751.50
|
| Rate for Payer: PHCS Commercial |
$5,424.00
|
| Rate for Payer: United Healthcare All Payer |
$4,972.00
|
|
|
Allopurinol 1mg (500mg SDV)
|
Facility
|
OP
|
$5,650.00
|
|
|
Service Code
|
HCPCS J0206
|
| Hospital Charge Code |
25002814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$5,424.00 |
| Rate for Payer: Aetna Commercial |
$4,350.50
|
| Rate for Payer: Anthem Medicaid |
$1,943.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,407.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.50
|
| Rate for Payer: Cash Price |
$2,825.00
|
| Rate for Payer: Cash Price |
$2,825.00
|
| Rate for Payer: Cigna Commercial |
$4,689.50
|
| Rate for Payer: First Health Commercial |
$5,367.50
|
| Rate for Payer: Humana Commercial |
$4,802.50
|
| Rate for Payer: Humana KY Medicaid |
$1,943.04
|
| Rate for Payer: Humana Medicare Advantage |
$5.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,962.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,633.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,169.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,982.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,972.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,237.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$734.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,751.50
|
| Rate for Payer: PHCS Commercial |
$5,424.00
|
| Rate for Payer: United Healthcare All Payer |
$4,972.00
|
|
|
ALLOSYNC DBM PUTTY 5CC
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
ALLOSYNC DBM PUTTY 5CC
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
ALLOSYNC PURE 5CC
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
ALLOSYNC PURE 5CC
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
|
|
ALOCRIL(NEDOCROMIL SOD) 2% DRP
|
Facility
|
IP
|
$394.51
|
|
|
Service Code
|
NDC 23884205
|
| Hospital Charge Code |
25000196
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.29 |
| Max. Negotiated Rate |
$378.73 |
| Rate for Payer: Aetna Commercial |
$303.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.72
|
| Rate for Payer: Cash Price |
$197.26
|
| Rate for Payer: Cigna Commercial |
$327.44
|
| Rate for Payer: First Health Commercial |
$374.78
|
| Rate for Payer: Humana Commercial |
$335.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$291.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$347.17
|
| Rate for Payer: Ohio Health Group HMO |
$295.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.30
|
| Rate for Payer: PHCS Commercial |
$378.73
|
| Rate for Payer: United Healthcare All Payer |
$347.17
|
|
|
ALOCRIL(NEDOCROMIL SOD) 2% DRP
|
Facility
|
OP
|
$394.51
|
|
|
Service Code
|
NDC 23884205
|
| Hospital Charge Code |
25000196
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.29 |
| Max. Negotiated Rate |
$378.73 |
| Rate for Payer: Anthem Medicaid |
$135.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.72
|
| Rate for Payer: Cash Price |
$197.26
|
| Rate for Payer: Cigna Commercial |
$327.44
|
| Rate for Payer: First Health Commercial |
$374.78
|
| Rate for Payer: Humana Commercial |
$335.33
|
| Rate for Payer: Humana KY Medicaid |
$135.67
|
| Rate for Payer: Kentucky WC Medicaid |
$137.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.50
|
| Rate for Payer: Aetna Commercial |
$303.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$291.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$138.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$347.17
|
| Rate for Payer: Ohio Health Group HMO |
$295.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.30
|
| Rate for Payer: PHCS Commercial |
$378.73
|
| Rate for Payer: United Healthcare All Payer |
$347.17
|
|
