|
FLEBOGAMMA 500mg(2.5gm) SDV
|
Facility
|
OP
|
$1,442.62
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.12 |
| Max. Negotiated Rate |
$1,384.92 |
| Rate for Payer: Aetna Commercial |
$1,110.82
|
| Rate for Payer: Anthem Medicaid |
$496.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$56.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,125.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.76
|
| Rate for Payer: Cash Price |
$721.31
|
| Rate for Payer: Cash Price |
$721.31
|
| Rate for Payer: Cigna Commercial |
$1,197.37
|
| Rate for Payer: First Health Commercial |
$1,370.49
|
| Rate for Payer: Humana Commercial |
$1,226.23
|
| Rate for Payer: Humana KY Medicaid |
$496.12
|
| Rate for Payer: Humana Medicare Advantage |
$56.12
|
| Rate for Payer: Kentucky WC Medicaid |
$501.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,182.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,064.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$506.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,269.51
|
| Rate for Payer: Ohio Health Group HMO |
$1,081.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$288.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.21
|
| Rate for Payer: PHCS Commercial |
$1,384.92
|
| Rate for Payer: United Healthcare All Payer |
$1,269.51
|
|
|
FLEBOGAMMA 500mg(2.5gm) SDV
|
Facility
|
IP
|
$1,442.62
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.54 |
| Max. Negotiated Rate |
$1,384.92 |
| Rate for Payer: Aetna Commercial |
$1,110.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,125.24
|
| Rate for Payer: Cash Price |
$721.31
|
| Rate for Payer: Cigna Commercial |
$1,197.37
|
| Rate for Payer: First Health Commercial |
$1,370.49
|
| Rate for Payer: Humana Commercial |
$1,226.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,182.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,064.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$432.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,269.51
|
| Rate for Payer: Ohio Health Group HMO |
$1,081.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$288.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.21
|
| Rate for Payer: PHCS Commercial |
$1,384.92
|
| Rate for Payer: United Healthcare All Payer |
$1,269.51
|
|
|
FLEBOGAMMA 500mg(5gm) SDV
|
Facility
|
IP
|
$2,885.23
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$375.08 |
| Max. Negotiated Rate |
$2,769.82 |
| Rate for Payer: Aetna Commercial |
$2,221.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,250.48
|
| Rate for Payer: Cash Price |
$1,442.62
|
| Rate for Payer: Cigna Commercial |
$2,394.74
|
| Rate for Payer: First Health Commercial |
$2,740.97
|
| Rate for Payer: Humana Commercial |
$2,452.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,365.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,129.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$865.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,539.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,163.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$577.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$375.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$894.42
|
| Rate for Payer: PHCS Commercial |
$2,769.82
|
| Rate for Payer: United Healthcare All Payer |
$2,539.00
|
|
|
FLEBOGAMMA 500mg(5gm) SDV
|
Facility
|
OP
|
$2,885.23
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.12 |
| Max. Negotiated Rate |
$2,769.82 |
| Rate for Payer: Aetna Commercial |
$2,221.63
|
| Rate for Payer: Anthem Medicaid |
$992.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$56.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,250.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.76
|
| Rate for Payer: Cash Price |
$1,442.62
|
| Rate for Payer: Cash Price |
$1,442.62
|
| Rate for Payer: Cigna Commercial |
$2,394.74
|
| Rate for Payer: First Health Commercial |
$2,740.97
|
| Rate for Payer: Humana Commercial |
$2,452.45
|
| Rate for Payer: Humana KY Medicaid |
$992.23
|
| Rate for Payer: Humana Medicare Advantage |
$56.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1,002.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,365.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,129.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,012.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,539.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,163.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$577.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$375.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$894.42
|
| Rate for Payer: PHCS Commercial |
$2,769.82
|
| Rate for Payer: United Healthcare All Payer |
$2,539.00
|
|
|
FLEETS PHOSPHO-SODA 1.5 1.5OZ
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 132020140
|
| Hospital Charge Code |
25000680
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
FLEETS PHOSPHO-SODA 1.5 1.5OZ
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 132020140
|
| Hospital Charge Code |
25000680
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
FLEXBAND ANCHOR W DRIVER
|
Facility
|
OP
|
$3,838.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.94 |
| Max. Negotiated Rate |
$3,684.48 |
| Rate for Payer: Aetna Commercial |
$2,955.26
|
| Rate for Payer: Anthem Medicaid |
$1,319.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.64
|
| Rate for Payer: Cash Price |
$1,919.00
|
| Rate for Payer: Cigna Commercial |
$3,185.54
|
| Rate for Payer: First Health Commercial |
$3,646.10
|
| Rate for Payer: Humana Commercial |
$3,262.30
|
| Rate for Payer: Humana KY Medicaid |
$1,319.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,333.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,147.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,346.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$498.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.78
|
| Rate for Payer: PHCS Commercial |
$3,684.48
|
| Rate for Payer: United Healthcare All Payer |
$3,377.44
|
|
|
FLEXBAND ANCHOR W DRIVER
|
Facility
|
IP
|
$3,838.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.94 |
| Max. Negotiated Rate |
$3,684.48 |
| Rate for Payer: Aetna Commercial |
$2,955.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.64
|
| Rate for Payer: Cash Price |
$1,919.00
|
| Rate for Payer: Cigna Commercial |
$3,185.54
|
| Rate for Payer: First Health Commercial |
$3,646.10
|
| Rate for Payer: Humana Commercial |
$3,262.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,147.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$498.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.78
|
| Rate for Payer: PHCS Commercial |
$3,684.48
|
| Rate for Payer: United Healthcare All Payer |
$3,377.44
|
|
|
FLEXBAND DYNAMIC MAT 0.5*16CM
|
Facility
|
IP
|
$12,917.75
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,679.31 |
| Max. Negotiated Rate |
$12,401.04 |
| Rate for Payer: Aetna Commercial |
$9,946.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,075.84
|
| Rate for Payer: Cash Price |
$6,458.88
|
| Rate for Payer: Cigna Commercial |
$10,721.73
|
| Rate for Payer: First Health Commercial |
$12,271.86
|
| Rate for Payer: Humana Commercial |
$10,980.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,592.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,533.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,875.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,367.62
|
| Rate for Payer: Ohio Health Group HMO |
$9,688.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,583.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,679.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,004.50
|
| Rate for Payer: PHCS Commercial |
$12,401.04
|
| Rate for Payer: United Healthcare All Payer |
$11,367.62
|
|
|
FLEXBAND DYNAMIC MAT 0.5*16CM
|
Facility
|
OP
|
$12,917.75
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,679.31 |
| Max. Negotiated Rate |
$12,401.04 |
| Rate for Payer: Aetna Commercial |
$9,946.67
|
| Rate for Payer: Anthem Medicaid |
$4,442.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,075.84
|
| Rate for Payer: Cash Price |
$6,458.88
|
| Rate for Payer: Cigna Commercial |
$10,721.73
|
| Rate for Payer: First Health Commercial |
$12,271.86
|
| Rate for Payer: Humana Commercial |
$10,980.09
|
| Rate for Payer: Humana KY Medicaid |
$4,442.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,487.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,592.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,533.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,875.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,531.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,367.62
|
| Rate for Payer: Ohio Health Group HMO |
$9,688.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,583.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,679.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,004.50
|
| Rate for Payer: PHCS Commercial |
$12,401.04
|
| Rate for Payer: United Healthcare All Payer |
$11,367.62
|
|
|
FLEXBAND MULTI KIT
|
Facility
|
IP
|
$17,955.60
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,334.23 |
| Max. Negotiated Rate |
$17,237.38 |
| Rate for Payer: Aetna Commercial |
$13,825.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,005.37
|
| Rate for Payer: Cash Price |
$8,977.80
|
| Rate for Payer: Cigna Commercial |
$14,903.15
|
| Rate for Payer: First Health Commercial |
$17,057.82
|
| Rate for Payer: Humana Commercial |
$15,262.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,723.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,251.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,386.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,800.93
|
| Rate for Payer: Ohio Health Group HMO |
$13,466.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,591.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,334.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,566.24
|
| Rate for Payer: PHCS Commercial |
$17,237.38
|
| Rate for Payer: United Healthcare All Payer |
$15,800.93
|
|
|
FLEXBAND MULTI KIT
|
Facility
|
OP
|
$17,955.60
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,334.23 |
| Max. Negotiated Rate |
$17,237.38 |
| Rate for Payer: Aetna Commercial |
$13,825.81
|
| Rate for Payer: Anthem Medicaid |
$6,174.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,005.37
|
| Rate for Payer: Cash Price |
$8,977.80
|
| Rate for Payer: Cigna Commercial |
$14,903.15
|
| Rate for Payer: First Health Commercial |
$17,057.82
|
| Rate for Payer: Humana Commercial |
$15,262.26
|
| Rate for Payer: Humana KY Medicaid |
$6,174.93
|
| Rate for Payer: Kentucky WC Medicaid |
$6,237.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,723.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,251.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,386.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,298.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,800.93
|
| Rate for Payer: Ohio Health Group HMO |
$13,466.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,591.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,334.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,566.24
|
| Rate for Payer: PHCS Commercial |
$17,237.38
|
| Rate for Payer: United Healthcare All Payer |
$15,800.93
|
|
|
FLEXBAND SOLO KIT
|
Facility
|
OP
|
$16,425.60
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,135.33 |
| Max. Negotiated Rate |
$15,768.58 |
| Rate for Payer: Aetna Commercial |
$12,647.71
|
| Rate for Payer: Anthem Medicaid |
$5,648.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.97
|
| Rate for Payer: Cash Price |
$8,212.80
|
| Rate for Payer: Cigna Commercial |
$13,633.25
|
| Rate for Payer: First Health Commercial |
$15,604.32
|
| Rate for Payer: Humana Commercial |
$13,961.76
|
| Rate for Payer: Humana KY Medicaid |
$5,648.76
|
| Rate for Payer: Kentucky WC Medicaid |
$5,706.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,122.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,762.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.53
|
| Rate for Payer: Ohio Health Group HMO |
$12,319.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,285.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,135.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,091.94
|
| Rate for Payer: PHCS Commercial |
$15,768.58
|
| Rate for Payer: United Healthcare All Payer |
$14,454.53
|
|
|
FLEXBAND SOLO KIT
|
Facility
|
IP
|
$16,425.60
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
27000281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,135.33 |
| Max. Negotiated Rate |
$15,768.58 |
| Rate for Payer: Aetna Commercial |
$12,647.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.97
|
| Rate for Payer: Cash Price |
$8,212.80
|
| Rate for Payer: Cigna Commercial |
$13,633.25
|
| Rate for Payer: First Health Commercial |
$15,604.32
|
| Rate for Payer: Humana Commercial |
$13,961.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,122.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.53
|
| Rate for Payer: Ohio Health Group HMO |
$12,319.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,285.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,135.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,091.94
|
| Rate for Payer: PHCS Commercial |
$15,768.58
|
| Rate for Payer: United Healthcare All Payer |
$14,454.53
|
|
|
FLEXERIL 5 MG TABLET
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 52817033010
|
| Hospital Charge Code |
25000681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
FLEXERIL 5 MG TABLET
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 52817033010
|
| Hospital Charge Code |
25000681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
FLEXERIL(CYCLOBENZAP 10MG/1TAB
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
25000682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
FLEXERIL(CYCLOBENZAP 10MG/1TAB
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 60687055801
|
| Hospital Charge Code |
25000682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
FLEX& EXT BEND VIEWS ONLY LUM
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
32000055
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.27
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
FLEX& EXT BEND VIEWS ONLY LUM
|
Professional
|
Both
|
$417.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
32000055
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$417.00 |
| Rate for Payer: Aetna Commercial |
$73.35
|
| Rate for Payer: Anthem Medicaid |
$33.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$417.00
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$69.82
|
| Rate for Payer: Healthspan PPO |
$68.73
|
| Rate for Payer: Humana Medicaid |
$33.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.31
|
| Rate for Payer: Molina Healthcare Passport |
$33.64
|
| Rate for Payer: Multiplan PHCS |
$250.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$291.90
|
| Rate for Payer: UHCCP Medicaid |
$145.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.98
|
|
|
FLEX& EXT BEND VIEWS ONLY LUM
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
32000055
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem Medicaid |
$143.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Humana KY Medicaid |
$143.41
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$144.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.27
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
FLEX& EXT BEND VIEWS ONLY LU(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
320P0055
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$73.35 |
| Rate for Payer: Aetna Commercial |
$73.35
|
| Rate for Payer: Anthem Medicaid |
$33.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$69.82
|
| Rate for Payer: Healthspan PPO |
$68.73
|
| Rate for Payer: Humana Medicaid |
$33.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.31
|
| Rate for Payer: Molina Healthcare Passport |
$33.64
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.98
|
|
|
FLEX& EXT BEND VIEWS ONLY LU(T
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
320T0055
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$352.32 |
| Rate for Payer: Aetna Commercial |
$282.59
|
| Rate for Payer: Anthem Medicaid |
$126.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$286.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$183.50
|
| Rate for Payer: Cash Price |
$183.50
|
| Rate for Payer: Cigna Commercial |
$304.61
|
| Rate for Payer: First Health Commercial |
$348.65
|
| Rate for Payer: Humana Commercial |
$311.95
|
| Rate for Payer: Humana KY Medicaid |
$126.21
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$300.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$270.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$128.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$322.96
|
| Rate for Payer: Ohio Health Group HMO |
$275.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.77
|
| Rate for Payer: PHCS Commercial |
$352.32
|
| Rate for Payer: United Healthcare All Payer |
$322.96
|
|
|
FLEX& EXT BEND VIEWS ONLY LU(T
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
HCPCS 72120
|
| Hospital Charge Code |
320T0055
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$352.32 |
| Rate for Payer: Aetna Commercial |
$282.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$286.26
|
| Rate for Payer: Cash Price |
$183.50
|
| Rate for Payer: Cigna Commercial |
$304.61
|
| Rate for Payer: First Health Commercial |
$348.65
|
| Rate for Payer: Humana Commercial |
$311.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$300.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$270.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$110.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$322.96
|
| Rate for Payer: Ohio Health Group HMO |
$275.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.77
|
| Rate for Payer: PHCS Commercial |
$352.32
|
| Rate for Payer: United Healthcare All Payer |
$322.96
|
|
|
FLEXON ANSEL SHEATH 6FR
|
Facility
|
IP
|
$1,512.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.62 |
| Max. Negotiated Rate |
$1,452.00 |
| Rate for Payer: Aetna Commercial |
$1,164.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,179.75
|
| Rate for Payer: Cash Price |
$756.25
|
| Rate for Payer: Cigna Commercial |
$1,255.38
|
| Rate for Payer: First Health Commercial |
$1,436.88
|
| Rate for Payer: Humana Commercial |
$1,285.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,240.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,116.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,331.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,134.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$302.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$196.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$468.88
|
| Rate for Payer: PHCS Commercial |
$1,452.00
|
| Rate for Payer: United Healthcare All Payer |
$1,331.00
|
|
