|
FAN LIME 11.5X48 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 11.5X48 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 11.5X50 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 11.5X50 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X30 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X30 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X32 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X32 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X34 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X34 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X36 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 13X36 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FARXIGA
|
Facility
|
OP
|
$36.99
|
|
|
Service Code
|
NDC 310620530
|
| Hospital Charge Code |
25003057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.51 |
| Rate for Payer: Aetna Commercial |
$28.48
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.85
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.70
|
| Rate for Payer: First Health Commercial |
$35.14
|
| Rate for Payer: Humana Commercial |
$31.44
|
| Rate for Payer: Humana KY Medicaid |
$12.72
|
| Rate for Payer: Kentucky WC Medicaid |
$12.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.55
|
| Rate for Payer: Ohio Health Group HMO |
$27.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.52
|
| Rate for Payer: PHCS Commercial |
$35.51
|
| Rate for Payer: United Healthcare All Payer |
$32.55
|
|
|
FARXIGA
|
Facility
|
IP
|
$36.99
|
|
|
Service Code
|
NDC 310620530
|
| Hospital Charge Code |
25003057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.51 |
| Rate for Payer: Aetna Commercial |
$28.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.85
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.70
|
| Rate for Payer: First Health Commercial |
$35.14
|
| Rate for Payer: Humana Commercial |
$31.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.55
|
| Rate for Payer: Ohio Health Group HMO |
$27.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.52
|
| Rate for Payer: PHCS Commercial |
$35.51
|
| Rate for Payer: United Healthcare All Payer |
$32.55
|
|
|
FARZIGA 10 MG TABLET
|
Facility
|
OP
|
$36.99
|
|
|
Service Code
|
NDC 310621030
|
| Hospital Charge Code |
25000663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.51 |
| Rate for Payer: Aetna Commercial |
$28.48
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.85
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.70
|
| Rate for Payer: First Health Commercial |
$35.14
|
| Rate for Payer: Humana Commercial |
$31.44
|
| Rate for Payer: Humana KY Medicaid |
$12.72
|
| Rate for Payer: Kentucky WC Medicaid |
$12.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.55
|
| Rate for Payer: Ohio Health Group HMO |
$27.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.52
|
| Rate for Payer: PHCS Commercial |
$35.51
|
| Rate for Payer: United Healthcare All Payer |
$32.55
|
|
|
FARZIGA 10 MG TABLET
|
Facility
|
IP
|
$36.99
|
|
|
Service Code
|
NDC 310621030
|
| Hospital Charge Code |
25000663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.51 |
| Rate for Payer: Aetna Commercial |
$28.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.85
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.70
|
| Rate for Payer: First Health Commercial |
$35.14
|
| Rate for Payer: Humana Commercial |
$31.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.55
|
| Rate for Payer: Ohio Health Group HMO |
$27.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.52
|
| Rate for Payer: PHCS Commercial |
$35.51
|
| Rate for Payer: United Healthcare All Payer |
$32.55
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
IP
|
$1,656.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
45000135
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$496.80 |
| Max. Negotiated Rate |
$1,589.76 |
| Rate for Payer: Aetna Commercial |
$1,275.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,291.68
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$1,374.48
|
| Rate for Payer: First Health Commercial |
$1,573.20
|
| Rate for Payer: Humana Commercial |
$1,407.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,357.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,222.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$496.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,457.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,242.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,324.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,440.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.64
|
| Rate for Payer: PHCS Commercial |
$1,589.76
|
| Rate for Payer: United Healthcare All Payer |
$1,457.28
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
76100674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.48 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$428.84
|
| Rate for Payer: Ambetter Exchange |
$254.11
|
| Rate for Payer: Anthem Medicaid |
$216.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$254.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$254.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$304.93
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$465.14
|
| Rate for Payer: Healthspan PPO |
$388.44
|
| Rate for Payer: Humana Medicaid |
$216.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$350.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$254.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$220.81
|
| Rate for Payer: Molina Healthcare Passport |
$216.48
|
| Rate for Payer: Multiplan PHCS |
$552.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$330.34
|
| Rate for Payer: UHCCP Medicaid |
$322.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$218.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$254.11
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
IP
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
76100674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.00 |
| Max. Negotiated Rate |
$883.20 |
| Rate for Payer: Aetna Commercial |
$708.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$717.60
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$763.60
|
| Rate for Payer: First Health Commercial |
$874.00
|
| Rate for Payer: Humana Commercial |
$782.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$754.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$678.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$809.60
|
| Rate for Payer: Ohio Health Group HMO |
$690.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$800.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$634.80
|
| Rate for Payer: PHCS Commercial |
$883.20
|
| Rate for Payer: United Healthcare All Payer |
$809.60
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
OP
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
76100674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.00 |
| Max. Negotiated Rate |
$883.20 |
| Rate for Payer: Aetna Commercial |
$708.40
|
| Rate for Payer: Anthem Medicaid |
$316.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$717.60
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$763.60
|
| Rate for Payer: First Health Commercial |
$874.00
|
| Rate for Payer: Humana Commercial |
$782.00
|
| Rate for Payer: Humana KY Medicaid |
$316.39
|
| Rate for Payer: Kentucky WC Medicaid |
$319.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$754.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$678.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$322.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$809.60
|
| Rate for Payer: Ohio Health Group HMO |
$690.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$800.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$634.80
|
| Rate for Payer: PHCS Commercial |
$883.20
|
| Rate for Payer: United Healthcare All Payer |
$809.60
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
OP
|
$1,656.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
45000135
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$496.80 |
| Max. Negotiated Rate |
$1,589.76 |
| Rate for Payer: Aetna Commercial |
$1,275.12
|
| Rate for Payer: Anthem Medicaid |
$569.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,291.68
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$1,374.48
|
| Rate for Payer: First Health Commercial |
$1,573.20
|
| Rate for Payer: Humana Commercial |
$1,407.60
|
| Rate for Payer: Humana KY Medicaid |
$569.50
|
| Rate for Payer: Kentucky WC Medicaid |
$575.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,357.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,222.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$496.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$580.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,457.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,242.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,324.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,440.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.64
|
| Rate for Payer: PHCS Commercial |
$1,589.76
|
| Rate for Payer: United Healthcare All Payer |
$1,457.28
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
761P0674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.48 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$428.84
|
| Rate for Payer: Ambetter Exchange |
$254.11
|
| Rate for Payer: Anthem Medicaid |
$216.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$254.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$254.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$304.93
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$465.14
|
| Rate for Payer: Healthspan PPO |
$388.44
|
| Rate for Payer: Humana Medicaid |
$216.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$350.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$254.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$220.81
|
| Rate for Payer: Molina Healthcare Passport |
$216.48
|
| Rate for Payer: Multiplan PHCS |
$552.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$330.34
|
| Rate for Payer: UHCCP Medicaid |
$322.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$218.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$254.11
|
|
|
FASCIA LATA 4*7CM
|
Facility
|
IP
|
$10,986.80
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,296.04 |
| Max. Negotiated Rate |
$10,547.33 |
| Rate for Payer: Aetna Commercial |
$8,459.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,569.70
|
| Rate for Payer: Cash Price |
$5,493.40
|
| Rate for Payer: Cigna Commercial |
$9,119.04
|
| Rate for Payer: First Health Commercial |
$10,437.46
|
| Rate for Payer: Humana Commercial |
$9,338.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,009.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,108.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,296.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,668.38
|
| Rate for Payer: Ohio Health Group HMO |
$8,240.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,789.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,558.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,580.89
|
| Rate for Payer: PHCS Commercial |
$10,547.33
|
| Rate for Payer: United Healthcare All Payer |
$9,668.38
|
|
|
FASCIA LATA 4*7CM
|
Facility
|
OP
|
$10,986.80
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,296.04 |
| Max. Negotiated Rate |
$10,547.33 |
| Rate for Payer: Aetna Commercial |
$8,459.84
|
| Rate for Payer: Anthem Medicaid |
$3,778.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,569.70
|
| Rate for Payer: Cash Price |
$5,493.40
|
| Rate for Payer: Cigna Commercial |
$9,119.04
|
| Rate for Payer: First Health Commercial |
$10,437.46
|
| Rate for Payer: Humana Commercial |
$9,338.78
|
| Rate for Payer: Humana KY Medicaid |
$3,778.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,816.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,009.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,108.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,296.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,854.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,668.38
|
| Rate for Payer: Ohio Health Group HMO |
$8,240.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,789.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,558.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,580.89
|
| Rate for Payer: PHCS Commercial |
$10,547.33
|
| Rate for Payer: United Healthcare All Payer |
$9,668.38
|
|
|
FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$4,197.13
|
|
|
Service Code
|
CPT 28060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,997.95 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
|
