|
ALYMSYS 10mg (100mg SDV)
|
Facility
|
OP
|
$3,916.37
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004320
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$3,759.72 |
| Rate for Payer: Aetna Commercial |
$3,015.60
|
| Rate for Payer: Anthem Medicaid |
$1,346.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$42.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,054.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$59.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.51
|
| Rate for Payer: Cash Price |
$1,958.18
|
| Rate for Payer: Cash Price |
$1,958.18
|
| Rate for Payer: Cigna Commercial |
$3,250.59
|
| Rate for Payer: First Health Commercial |
$3,720.55
|
| Rate for Payer: Humana Commercial |
$3,328.91
|
| Rate for Payer: Humana KY Medicaid |
$1,346.84
|
| Rate for Payer: Humana Medicare Advantage |
$42.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,360.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,211.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,890.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,373.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,446.41
|
| Rate for Payer: Ohio Health Group HMO |
$2,937.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,133.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,407.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,702.30
|
| Rate for Payer: PHCS Commercial |
$3,759.72
|
| Rate for Payer: United Healthcare All Payer |
$3,446.41
|
|
|
ALYMSYS 10mg (400mg SDV)
|
Facility
|
OP
|
$15,665.48
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$15,038.86 |
| Rate for Payer: Aetna Commercial |
$12,062.42
|
| Rate for Payer: Anthem Medicaid |
$5,387.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$42.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,219.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$59.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.51
|
| Rate for Payer: Cash Price |
$7,832.74
|
| Rate for Payer: Cash Price |
$7,832.74
|
| Rate for Payer: Cigna Commercial |
$13,002.35
|
| Rate for Payer: First Health Commercial |
$14,882.21
|
| Rate for Payer: Humana Commercial |
$13,315.66
|
| Rate for Payer: Humana KY Medicaid |
$5,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$42.60
|
| Rate for Payer: Kentucky WC Medicaid |
$5,442.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,845.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,561.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,495.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,785.62
|
| Rate for Payer: Ohio Health Group HMO |
$11,749.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,532.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,628.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,809.18
|
| Rate for Payer: PHCS Commercial |
$15,038.86
|
| Rate for Payer: United Healthcare All Payer |
$13,785.62
|
|
|
ALYMSYS 10mg (400mg SDV)
|
Facility
|
IP
|
$15,665.48
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,699.64 |
| Max. Negotiated Rate |
$15,038.86 |
| Rate for Payer: Aetna Commercial |
$12,062.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,219.07
|
| Rate for Payer: Cash Price |
$7,832.74
|
| Rate for Payer: Cigna Commercial |
$13,002.35
|
| Rate for Payer: First Health Commercial |
$14,882.21
|
| Rate for Payer: Humana Commercial |
$13,315.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,845.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,561.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,699.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,785.62
|
| Rate for Payer: Ohio Health Group HMO |
$11,749.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,532.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,628.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,809.18
|
| Rate for Payer: PHCS Commercial |
$15,038.86
|
| Rate for Payer: United Healthcare All Payer |
$13,785.62
|
|
|
ALYS SMPL SP/PN NPGT W/PRGRM
|
Facility
|
OP
|
$1,143.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
51000042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$84.81 |
| Max. Negotiated Rate |
$1,097.28 |
| Rate for Payer: Aetna Commercial |
$880.11
|
| Rate for Payer: Anthem Medicaid |
$393.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$84.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$891.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$118.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.49
|
| Rate for Payer: Cash Price |
$571.50
|
| Rate for Payer: Cash Price |
$571.50
|
| Rate for Payer: Cigna Commercial |
$948.69
|
| Rate for Payer: First Health Commercial |
$1,085.85
|
| Rate for Payer: Humana Commercial |
$971.55
|
| Rate for Payer: Humana KY Medicaid |
$393.08
|
| Rate for Payer: Humana Medicare Advantage |
$84.81
|
| Rate for Payer: Kentucky WC Medicaid |
$397.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$937.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$843.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$400.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,005.84
|
| Rate for Payer: Ohio Health Group HMO |
$857.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$914.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$994.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$788.67
|
| Rate for Payer: PHCS Commercial |
$1,097.28
|
| Rate for Payer: United Healthcare All Payer |
$1,005.84
|
|
|
ALYS SMPL SP/PN NPGT W/PRGRM
|
Facility
|
IP
|
$1,143.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
51000042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$342.90 |
| Max. Negotiated Rate |
$1,097.28 |
| Rate for Payer: Aetna Commercial |
$880.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$891.54
|
| Rate for Payer: Cash Price |
$571.50
|
| Rate for Payer: Cigna Commercial |
$948.69
|
| Rate for Payer: First Health Commercial |
$1,085.85
|
| Rate for Payer: Humana Commercial |
$971.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$937.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$843.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,005.84
|
| Rate for Payer: Ohio Health Group HMO |
$857.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$914.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$994.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$788.67
|
| Rate for Payer: PHCS Commercial |
$1,097.28
|
| Rate for Payer: United Healthcare All Payer |
$1,005.84
|
|
|
ALYS SMPL SP/PN NPGT W/PRGRM
|
Professional
|
Both
|
$1,143.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
51000042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$685.80 |
| Rate for Payer: Aetna Commercial |
$63.94
|
| Rate for Payer: Ambetter Exchange |
$36.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$20.25
|
| Rate for Payer: Anthem Medicaid |
$31.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$36.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$36.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$43.64
|
| Rate for Payer: Cash Price |
$571.50
|
| Rate for Payer: Cash Price |
$571.50
|
| Rate for Payer: Cigna Commercial |
$83.82
|
| Rate for Payer: Healthspan PPO |
$77.99
|
| Rate for Payer: Humana Medicaid |
$31.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$36.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.06
|
| Rate for Payer: Molina Healthcare Passport |
$31.43
|
| Rate for Payer: Multiplan PHCS |
$685.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$47.28
|
| Rate for Payer: UHCCP Medicaid |
$21.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$31.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$36.37
|
|
|
ALYS SMPL SP/PN NPGT W/PRGR(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
510P0042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$63.94
|
| Rate for Payer: Ambetter Exchange |
$36.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$20.25
|
| Rate for Payer: Anthem Medicaid |
$31.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$36.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$36.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$43.64
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$83.82
|
| Rate for Payer: Healthspan PPO |
$77.99
|
| Rate for Payer: Humana Medicaid |
$31.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$36.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.06
|
| Rate for Payer: Molina Healthcare Passport |
$31.43
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$47.28
|
| Rate for Payer: UHCCP Medicaid |
$21.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$31.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$36.37
|
|
|
ALYS SMPL SP/PN NPGT W/PRGR(T
|
Facility
|
IP
|
$993.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
510T0042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$953.28 |
| Rate for Payer: Aetna Commercial |
$764.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$774.54
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cigna Commercial |
$824.19
|
| Rate for Payer: First Health Commercial |
$943.35
|
| Rate for Payer: Humana Commercial |
$844.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$814.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$732.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$297.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$873.84
|
| Rate for Payer: Ohio Health Group HMO |
$744.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$794.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$863.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$685.17
|
| Rate for Payer: PHCS Commercial |
$953.28
|
| Rate for Payer: United Healthcare All Payer |
$873.84
|
|
|
ALYS SMPL SP/PN NPGT W/PRGR(T
|
Facility
|
OP
|
$993.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
510T0042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$84.81 |
| Max. Negotiated Rate |
$953.28 |
| Rate for Payer: Aetna Commercial |
$764.61
|
| Rate for Payer: Anthem Medicaid |
$341.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$84.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$774.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$118.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.49
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cigna Commercial |
$824.19
|
| Rate for Payer: First Health Commercial |
$943.35
|
| Rate for Payer: Humana Commercial |
$844.05
|
| Rate for Payer: Humana KY Medicaid |
$341.49
|
| Rate for Payer: Humana Medicare Advantage |
$84.81
|
| Rate for Payer: Kentucky WC Medicaid |
$344.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$814.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$732.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$348.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$873.84
|
| Rate for Payer: Ohio Health Group HMO |
$744.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$794.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$863.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$685.17
|
| Rate for Payer: PHCS Commercial |
$953.28
|
| Rate for Payer: United Healthcare All Payer |
$873.84
|
|
|
AMANTADINE SYRUP 50 MG / 5 ML
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
NDC 121064616
|
| Hospital Charge Code |
25002521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
AMANTADINE SYRUP 50 MG / 5 ML
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
NDC 121064616
|
| Hospital Charge Code |
25002521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
AMARYL (GLIMEPRIDE) 2MG/1TAB
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 50268035915
|
| Hospital Charge Code |
25000205
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
AMARYL (GLIMEPRIDE) 2MG/1TAB
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 50268035915
|
| Hospital Charge Code |
25000205
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
AMBIOTIC MEMBRANE 1.5*2CM
|
Facility
|
IP
|
$3,871.25
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.38 |
| Max. Negotiated Rate |
$3,716.40 |
| Rate for Payer: Aetna Commercial |
$2,980.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,019.57
|
| Rate for Payer: Cash Price |
$1,935.62
|
| Rate for Payer: Cigna Commercial |
$3,213.14
|
| Rate for Payer: First Health Commercial |
$3,677.69
|
| Rate for Payer: Humana Commercial |
$3,290.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,174.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,856.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,161.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,406.70
|
| Rate for Payer: Ohio Health Group HMO |
$2,903.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,367.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,671.16
|
| Rate for Payer: PHCS Commercial |
$3,716.40
|
| Rate for Payer: United Healthcare All Payer |
$3,406.70
|
|
|
AMBIOTIC MEMBRANE 1.5*2CM
|
Facility
|
OP
|
$3,871.25
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.38 |
| Max. Negotiated Rate |
$3,716.40 |
| Rate for Payer: Aetna Commercial |
$2,980.86
|
| Rate for Payer: Anthem Medicaid |
$1,331.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,019.57
|
| Rate for Payer: Cash Price |
$1,935.62
|
| Rate for Payer: Cigna Commercial |
$3,213.14
|
| Rate for Payer: First Health Commercial |
$3,677.69
|
| Rate for Payer: Humana Commercial |
$3,290.56
|
| Rate for Payer: Humana KY Medicaid |
$1,331.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,344.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,174.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,856.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,161.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,358.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,406.70
|
| Rate for Payer: Ohio Health Group HMO |
$2,903.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,367.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,671.16
|
| Rate for Payer: PHCS Commercial |
$3,716.40
|
| Rate for Payer: United Healthcare All Payer |
$3,406.70
|
|
|
AMBI PLATE 10 SLOT 130*220MM
|
Facility
|
OP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem Medicaid |
$1,264.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Humana KY Medicaid |
$1,264.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,277.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 10 SLOT 130*220MM
|
Facility
|
IP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 10 SLOT 135*220MM
|
Facility
|
IP
|
$4,728.12
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.44 |
| Max. Negotiated Rate |
$4,539.00 |
| Rate for Payer: Aetna Commercial |
$3,640.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,687.93
|
| Rate for Payer: Cash Price |
$2,364.06
|
| Rate for Payer: Cigna Commercial |
$3,924.34
|
| Rate for Payer: First Health Commercial |
$4,491.71
|
| Rate for Payer: Humana Commercial |
$4,018.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,877.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,489.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,418.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,160.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,546.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,782.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,113.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,262.40
|
| Rate for Payer: PHCS Commercial |
$4,539.00
|
| Rate for Payer: United Healthcare All Payer |
$4,160.75
|
|
|
AMBI PLATE 10 SLOT 135*220MM
|
Facility
|
OP
|
$4,728.12
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.44 |
| Max. Negotiated Rate |
$4,539.00 |
| Rate for Payer: Aetna Commercial |
$3,640.65
|
| Rate for Payer: Anthem Medicaid |
$1,626.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,687.93
|
| Rate for Payer: Cash Price |
$2,364.06
|
| Rate for Payer: Cigna Commercial |
$3,924.34
|
| Rate for Payer: First Health Commercial |
$4,491.71
|
| Rate for Payer: Humana Commercial |
$4,018.90
|
| Rate for Payer: Humana KY Medicaid |
$1,626.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,642.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,877.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,489.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,418.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,658.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,160.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,546.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,782.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,113.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,262.40
|
| Rate for Payer: PHCS Commercial |
$4,539.00
|
| Rate for Payer: United Healthcare All Payer |
$4,160.75
|
|
|
AMBI PLATE 10 SLOT 140*220MM
|
Facility
|
IP
|
$4,729.06
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.72 |
| Max. Negotiated Rate |
$4,539.90 |
| Rate for Payer: Aetna Commercial |
$3,641.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,688.67
|
| Rate for Payer: Cash Price |
$2,364.53
|
| Rate for Payer: Cigna Commercial |
$3,925.12
|
| Rate for Payer: First Health Commercial |
$4,492.61
|
| Rate for Payer: Humana Commercial |
$4,019.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,877.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,490.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,418.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,161.57
|
| Rate for Payer: Ohio Health Group HMO |
$3,546.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,783.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,114.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,263.05
|
| Rate for Payer: PHCS Commercial |
$4,539.90
|
| Rate for Payer: United Healthcare All Payer |
$4,161.57
|
|
|
AMBI PLATE 10 SLOT 140*220MM
|
Facility
|
OP
|
$4,729.06
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.72 |
| Max. Negotiated Rate |
$4,539.90 |
| Rate for Payer: Aetna Commercial |
$3,641.38
|
| Rate for Payer: Anthem Medicaid |
$1,626.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,688.67
|
| Rate for Payer: Cash Price |
$2,364.53
|
| Rate for Payer: Cigna Commercial |
$3,925.12
|
| Rate for Payer: First Health Commercial |
$4,492.61
|
| Rate for Payer: Humana Commercial |
$4,019.70
|
| Rate for Payer: Humana KY Medicaid |
$1,626.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,642.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,877.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,490.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,418.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,658.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,161.57
|
| Rate for Payer: Ohio Health Group HMO |
$3,546.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,783.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,114.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,263.05
|
| Rate for Payer: PHCS Commercial |
$4,539.90
|
| Rate for Payer: United Healthcare All Payer |
$4,161.57
|
|
|
AMBI PLATE 10 SLOT 145*220MM
|
Facility
|
IP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 10 SLOT 145*220MM
|
Facility
|
OP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem Medicaid |
$1,264.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Humana KY Medicaid |
$1,264.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,277.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 10 SLOT 150*220M
|
Facility
|
IP
|
$4,726.81
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.04 |
| Max. Negotiated Rate |
$4,537.74 |
| Rate for Payer: Aetna Commercial |
$3,639.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,686.91
|
| Rate for Payer: Cash Price |
$2,363.41
|
| Rate for Payer: Cigna Commercial |
$3,923.25
|
| Rate for Payer: First Health Commercial |
$4,490.47
|
| Rate for Payer: Humana Commercial |
$4,017.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,875.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,488.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,418.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,159.59
|
| Rate for Payer: Ohio Health Group HMO |
$3,545.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,781.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,112.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,261.50
|
| Rate for Payer: PHCS Commercial |
$4,537.74
|
| Rate for Payer: United Healthcare All Payer |
$4,159.59
|
|
|
AMBI PLATE 10 SLOT 150*220M
|
Facility
|
OP
|
$4,726.81
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.04 |
| Max. Negotiated Rate |
$4,537.74 |
| Rate for Payer: Aetna Commercial |
$3,639.64
|
| Rate for Payer: Anthem Medicaid |
$1,625.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,686.91
|
| Rate for Payer: Cash Price |
$2,363.41
|
| Rate for Payer: Cigna Commercial |
$3,923.25
|
| Rate for Payer: First Health Commercial |
$4,490.47
|
| Rate for Payer: Humana Commercial |
$4,017.79
|
| Rate for Payer: Humana KY Medicaid |
$1,625.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,642.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,875.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,488.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,418.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,658.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,159.59
|
| Rate for Payer: Ohio Health Group HMO |
$3,545.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,781.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,112.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,261.50
|
| Rate for Payer: PHCS Commercial |
$4,537.74
|
| Rate for Payer: United Healthcare All Payer |
$4,159.59
|
|
