|
ALLOMEND MESH SHAPED 10*18CM
|
Facility
|
OP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem Medicaid |
$8,812.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Humana KY Medicaid |
$8,812.44
|
| Rate for Payer: Kentucky WC Medicaid |
$8,902.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,989.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
ALLOMEND MESH SHAPED 10*18CM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
ALLOMEND MESH XL ADM 1.1
|
Facility
|
IP
|
$36,125.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,837.50 |
| Max. Negotiated Rate |
$34,680.00 |
| Rate for Payer: Aetna Commercial |
$27,816.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,177.50
|
| Rate for Payer: Cash Price |
$18,062.50
|
| Rate for Payer: Cigna Commercial |
$29,983.75
|
| Rate for Payer: First Health Commercial |
$34,318.75
|
| Rate for Payer: Humana Commercial |
$30,706.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,622.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,660.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,837.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,790.00
|
| Rate for Payer: Ohio Health Group HMO |
$27,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,900.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,428.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,926.25
|
| Rate for Payer: PHCS Commercial |
$34,680.00
|
| Rate for Payer: United Healthcare All Payer |
$31,790.00
|
|
|
ALLOMEND MESH XL ADM 1.1
|
Facility
|
OP
|
$36,125.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,837.50 |
| Max. Negotiated Rate |
$34,680.00 |
| Rate for Payer: Aetna Commercial |
$27,816.25
|
| Rate for Payer: Anthem Medicaid |
$12,423.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,177.50
|
| Rate for Payer: Cash Price |
$18,062.50
|
| Rate for Payer: Cigna Commercial |
$29,983.75
|
| Rate for Payer: First Health Commercial |
$34,318.75
|
| Rate for Payer: Humana Commercial |
$30,706.25
|
| Rate for Payer: Humana KY Medicaid |
$12,423.39
|
| Rate for Payer: Kentucky WC Medicaid |
$12,549.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,622.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,660.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,837.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,672.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,790.00
|
| Rate for Payer: Ohio Health Group HMO |
$27,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,900.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,428.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,926.25
|
| Rate for Payer: PHCS Commercial |
$34,680.00
|
| Rate for Payer: United Healthcare All Payer |
$31,790.00
|
|
|
ALLOPATCH PLIABLE 2*2CM
|
Facility
|
IP
|
$3,348.65
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.60 |
| Max. Negotiated Rate |
$3,214.70 |
| Rate for Payer: Aetna Commercial |
$2,578.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,611.95
|
| Rate for Payer: Cash Price |
$1,674.33
|
| Rate for Payer: Cigna Commercial |
$2,779.38
|
| Rate for Payer: First Health Commercial |
$3,181.22
|
| Rate for Payer: Humana Commercial |
$2,846.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,745.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,471.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,004.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,946.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,511.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,678.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,913.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,310.57
|
| Rate for Payer: PHCS Commercial |
$3,214.70
|
| Rate for Payer: United Healthcare All Payer |
$2,946.81
|
|
|
ALLOPATCH PLIABLE 2*2CM
|
Facility
|
OP
|
$3,348.65
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.60 |
| Max. Negotiated Rate |
$3,214.70 |
| Rate for Payer: Aetna Commercial |
$2,578.46
|
| Rate for Payer: Anthem Medicaid |
$1,151.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,611.95
|
| Rate for Payer: Cash Price |
$1,674.33
|
| Rate for Payer: Cigna Commercial |
$2,779.38
|
| Rate for Payer: First Health Commercial |
$3,181.22
|
| Rate for Payer: Humana Commercial |
$2,846.35
|
| Rate for Payer: Humana KY Medicaid |
$1,151.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,163.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,745.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,471.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,004.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,174.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,946.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,511.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,678.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,913.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,310.57
|
| Rate for Payer: PHCS Commercial |
$3,214.70
|
| Rate for Payer: United Healthcare All Payer |
$2,946.81
|
|
|
Allopurinol 1mg (500mg SDV)
|
Facility
|
OP
|
$5,650.00
|
|
|
Service Code
|
HCPCS J0206
|
| Hospital Charge Code |
25002814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.54 |
| 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 |
$4.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,407.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.13
|
| 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 |
$4.54
|
| 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 |
$5.45
|
| 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 |
$4,520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,915.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,898.50
|
| Rate for Payer: PHCS Commercial |
$5,424.00
|
| Rate for Payer: United Healthcare All Payer |
$4,972.00
|
|
|
Allopurinol 1mg (500mg SDV)
|
Facility
|
IP
|
$5,650.00
|
|
|
Service Code
|
HCPCS J0206
|
| Hospital Charge Code |
25002814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,695.00 |
| 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 |
$4,520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,915.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,898.50
|
| Rate for Payer: PHCS Commercial |
$5,424.00
|
| Rate for Payer: United Healthcare All Payer |
$4,972.00
|
|
|
ALLOSYNC DBM PUTTY 5CC
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| 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 |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
ALLOSYNC DBM PUTTY 5CC
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| 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 |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
ALLOSYNC PURE 5CC
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
ALLOSYNC PURE 5CC
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
ALLOSYNC��� DBM GEL 1CC
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem Medicaid |
$708.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Humana KY Medicaid |
$708.43
|
| Rate for Payer: Kentucky WC Medicaid |
$715.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
ALLOSYNC��� DBM GEL 1CC
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
ALOCRIL(NEDOCROMIL SOD) 2% DRP
|
Facility
|
OP
|
$394.51
|
|
|
Service Code
|
NDC 23884205
|
| Hospital Charge Code |
25000196
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.35 |
| Max. Negotiated Rate |
$378.73 |
| Rate for Payer: Aetna Commercial |
$303.77
|
| 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: 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 |
$315.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$343.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.21
|
| Rate for Payer: PHCS Commercial |
$378.73
|
| Rate for Payer: United Healthcare All Payer |
$347.17
|
|
|
ALOCRIL(NEDOCROMIL SOD) 2% DRP
|
Facility
|
IP
|
$394.51
|
|
|
Service Code
|
NDC 23884205
|
| Hospital Charge Code |
25000196
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.35 |
| 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 |
$315.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$343.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.21
|
| Rate for Payer: PHCS Commercial |
$378.73
|
| Rate for Payer: United Healthcare All Payer |
$347.17
|
|
|
ALOXI 0.025MG (0.25MG/5ML VL)
|
Facility
|
IP
|
$98.10
|
|
|
Service Code
|
HCPCS J2469
|
| Hospital Charge Code |
25002303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$94.18 |
| Rate for Payer: Aetna Commercial |
$75.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.52
|
| Rate for Payer: Cash Price |
$49.05
|
| Rate for Payer: Cigna Commercial |
$81.42
|
| Rate for Payer: First Health Commercial |
$93.19
|
| Rate for Payer: Humana Commercial |
$83.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.33
|
| Rate for Payer: Ohio Health Group HMO |
$73.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.69
|
| Rate for Payer: PHCS Commercial |
$94.18
|
| Rate for Payer: United Healthcare All Payer |
$86.33
|
|
|
ALOXI 0.025MG (0.25MG/5ML VL)
|
Facility
|
OP
|
$98.10
|
|
|
Service Code
|
HCPCS J2469
|
| Hospital Charge Code |
25002303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$94.18 |
| Rate for Payer: Aetna Commercial |
$75.54
|
| Rate for Payer: Anthem Medicaid |
$33.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.52
|
| Rate for Payer: Cash Price |
$49.05
|
| Rate for Payer: Cigna Commercial |
$81.42
|
| Rate for Payer: First Health Commercial |
$93.19
|
| Rate for Payer: Humana Commercial |
$83.39
|
| Rate for Payer: Humana KY Medicaid |
$33.74
|
| Rate for Payer: Kentucky WC Medicaid |
$34.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.33
|
| Rate for Payer: Ohio Health Group HMO |
$73.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.69
|
| Rate for Payer: PHCS Commercial |
$94.18
|
| Rate for Payer: United Healthcare All Payer |
$86.33
|
|
|
ALPHAGAN 0.15% EYE DROPS
|
Facility
|
IP
|
$5.71
|
|
|
Service Code
|
NDC 61314014405
|
| Hospital Charge Code |
25000197
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Aetna Commercial |
$4.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.45
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna Commercial |
$4.74
|
| Rate for Payer: First Health Commercial |
$5.42
|
| Rate for Payer: Humana Commercial |
$4.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.02
|
| Rate for Payer: Ohio Health Group HMO |
$4.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.94
|
| Rate for Payer: PHCS Commercial |
$5.48
|
| Rate for Payer: United Healthcare All Payer |
$5.02
|
|
|
ALPHAGAN 0.15% EYE DROPS
|
Facility
|
OP
|
$5.71
|
|
|
Service Code
|
NDC 61314014405
|
| Hospital Charge Code |
25000197
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Aetna Commercial |
$4.40
|
| Rate for Payer: Anthem Medicaid |
$1.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.45
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna Commercial |
$4.74
|
| Rate for Payer: First Health Commercial |
$5.42
|
| Rate for Payer: Humana Commercial |
$4.85
|
| Rate for Payer: Humana KY Medicaid |
$1.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.02
|
| Rate for Payer: Ohio Health Group HMO |
$4.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.94
|
| Rate for Payer: PHCS Commercial |
$5.48
|
| Rate for Payer: United Healthcare All Payer |
$5.02
|
|
|
ALPHAGAN P 0.1% 5ML
|
Facility
|
IP
|
$6.12
|
|
|
Service Code
|
NDC 23932105
|
| Hospital Charge Code |
25000199
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna Commercial |
$4.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.77
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna Commercial |
$5.08
|
| Rate for Payer: First Health Commercial |
$5.81
|
| Rate for Payer: Humana Commercial |
$5.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.39
|
| Rate for Payer: Ohio Health Group HMO |
$4.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.22
|
| Rate for Payer: PHCS Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
ALPHAGAN P 0.1% 5ML
|
Facility
|
OP
|
$6.12
|
|
|
Service Code
|
NDC 23932105
|
| Hospital Charge Code |
25000199
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna Commercial |
$4.71
|
| Rate for Payer: Anthem Medicaid |
$2.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.77
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna Commercial |
$5.08
|
| Rate for Payer: First Health Commercial |
$5.81
|
| Rate for Payer: Humana Commercial |
$5.20
|
| Rate for Payer: Humana KY Medicaid |
$2.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.39
|
| Rate for Payer: Ohio Health Group HMO |
$4.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.22
|
| Rate for Payer: PHCS Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
ALPROSTADIL 1.25mcg(20mcg SDV)
|
Facility
|
OP
|
$572.30
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
25004492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.69 |
| Max. Negotiated Rate |
$549.41 |
| Rate for Payer: Aetna Commercial |
$440.67
|
| Rate for Payer: Anthem Medicaid |
$196.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$446.39
|
| Rate for Payer: Cash Price |
$286.15
|
| Rate for Payer: Cigna Commercial |
$475.01
|
| Rate for Payer: First Health Commercial |
$543.68
|
| Rate for Payer: Humana Commercial |
$486.45
|
| Rate for Payer: Humana KY Medicaid |
$196.81
|
| Rate for Payer: Kentucky WC Medicaid |
$198.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$469.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$422.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$200.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$503.62
|
| Rate for Payer: Ohio Health Group HMO |
$429.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$497.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$394.89
|
| Rate for Payer: PHCS Commercial |
$549.41
|
| Rate for Payer: United Healthcare All Payer |
$503.62
|
|
|
ALPROSTADIL 1.25mcg(20mcg SDV)
|
Facility
|
IP
|
$572.30
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
25004492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.69 |
| Max. Negotiated Rate |
$549.41 |
| Rate for Payer: Aetna Commercial |
$440.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$446.39
|
| Rate for Payer: Cash Price |
$286.15
|
| Rate for Payer: Cigna Commercial |
$475.01
|
| Rate for Payer: First Health Commercial |
$543.68
|
| Rate for Payer: Humana Commercial |
$486.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$469.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$422.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$503.62
|
| Rate for Payer: Ohio Health Group HMO |
$429.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$497.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$394.89
|
| Rate for Payer: PHCS Commercial |
$549.41
|
| Rate for Payer: United Healthcare All Payer |
$503.62
|
|
|
ALPROSTADIL 1.25mcg(40mcg SDV)
|
Facility
|
IP
|
$747.47
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
25004268
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$224.24 |
| Max. Negotiated Rate |
$717.57 |
| Rate for Payer: Aetna Commercial |
$575.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$583.03
|
| Rate for Payer: Cash Price |
$373.74
|
| Rate for Payer: Cigna Commercial |
$620.40
|
| Rate for Payer: First Health Commercial |
$710.10
|
| Rate for Payer: Humana Commercial |
$635.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$612.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$551.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$224.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$657.77
|
| Rate for Payer: Ohio Health Group HMO |
$560.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$597.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$515.75
|
| Rate for Payer: PHCS Commercial |
$717.57
|
| Rate for Payer: United Healthcare All Payer |
$657.77
|
|
