|
G3 L GAMMA KIT 11*400*130 R TI
|
Facility
|
OP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem Medicaid |
$2,549.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Humana KY Medicaid |
$2,549.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*420*130 L TI
|
Facility
|
IP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*420*130 L TI
|
Facility
|
OP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem Medicaid |
$2,549.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Humana KY Medicaid |
$2,549.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*420*130 R TI
|
Facility
|
OP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem Medicaid |
$2,549.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Humana KY Medicaid |
$2,549.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*420*130 R TI
|
Facility
|
IP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*440*130 L TI
|
Facility
|
OP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem Medicaid |
$2,549.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Humana KY Medicaid |
$2,549.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*440*130 L TI
|
Facility
|
IP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*440*130 R TI
|
Facility
|
IP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 L GAMMA KIT 11*440*130 R TI
|
Facility
|
OP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem Medicaid |
$2,549.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Humana KY Medicaid |
$2,549.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
G3 TROCHAN NAIL KIT 11*180*125
|
Facility
|
OP
|
$6,538.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$850.04 |
| Max. Negotiated Rate |
$6,277.22 |
| Rate for Payer: Aetna Commercial |
$5,034.85
|
| Rate for Payer: Anthem Medicaid |
$2,248.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,100.24
|
| Rate for Payer: Cash Price |
$3,269.38
|
| Rate for Payer: Cigna Commercial |
$5,427.18
|
| Rate for Payer: First Health Commercial |
$6,211.83
|
| Rate for Payer: Humana Commercial |
$5,557.95
|
| Rate for Payer: Humana KY Medicaid |
$2,248.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,271.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,361.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,825.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,961.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,293.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,754.12
|
| Rate for Payer: Ohio Health Group HMO |
$4,904.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$850.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,027.02
|
| Rate for Payer: PHCS Commercial |
$6,277.22
|
| Rate for Payer: United Healthcare All Payer |
$5,754.12
|
|
|
G3 TROCHAN NAIL KIT 11*180*125
|
Facility
|
IP
|
$6,538.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$850.04 |
| Max. Negotiated Rate |
$6,277.22 |
| Rate for Payer: Aetna Commercial |
$5,034.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,100.24
|
| Rate for Payer: Cash Price |
$3,269.38
|
| Rate for Payer: Cigna Commercial |
$5,427.18
|
| Rate for Payer: First Health Commercial |
$6,211.83
|
| Rate for Payer: Humana Commercial |
$5,557.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,361.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,825.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,961.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,754.12
|
| Rate for Payer: Ohio Health Group HMO |
$4,904.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$850.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,027.02
|
| Rate for Payer: PHCS Commercial |
$6,277.22
|
| Rate for Payer: United Healthcare All Payer |
$5,754.12
|
|
|
G7 VIT E NEUTRAL LNR 36MM E
|
Facility
|
OP
|
$10,746.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,396.98 |
| Max. Negotiated Rate |
$10,316.16 |
| Rate for Payer: Aetna Commercial |
$8,274.42
|
| Rate for Payer: Anthem Medicaid |
$3,695.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,381.88
|
| Rate for Payer: Cash Price |
$5,373.00
|
| Rate for Payer: Cigna Commercial |
$8,919.18
|
| Rate for Payer: First Health Commercial |
$10,208.70
|
| Rate for Payer: Humana Commercial |
$9,134.10
|
| Rate for Payer: Humana KY Medicaid |
$3,695.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3,733.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,811.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,930.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,223.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,769.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,456.48
|
| Rate for Payer: Ohio Health Group HMO |
$8,059.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,149.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,396.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,331.26
|
| Rate for Payer: PHCS Commercial |
$10,316.16
|
| Rate for Payer: United Healthcare All Payer |
$9,456.48
|
|
|
G7 VIT E NEUTRAL LNR 36MM E
|
Facility
|
IP
|
$10,746.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,396.98 |
| Max. Negotiated Rate |
$10,316.16 |
| Rate for Payer: Aetna Commercial |
$8,274.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,381.88
|
| Rate for Payer: Cash Price |
$5,373.00
|
| Rate for Payer: Cigna Commercial |
$8,919.18
|
| Rate for Payer: First Health Commercial |
$10,208.70
|
| Rate for Payer: Humana Commercial |
$9,134.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,811.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,930.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,223.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,456.48
|
| Rate for Payer: Ohio Health Group HMO |
$8,059.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,149.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,396.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,331.26
|
| Rate for Payer: PHCS Commercial |
$10,316.16
|
| Rate for Payer: United Healthcare All Payer |
$9,456.48
|
|
|
GABITRIL 12MG TAB
|
Facility
|
OP
|
$25.73
|
|
|
Service Code
|
NDC 93807256
|
| Hospital Charge Code |
25000708
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Anthem Medicaid |
$8.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.07
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna Commercial |
$21.36
|
| Rate for Payer: First Health Commercial |
$24.44
|
| Rate for Payer: Humana Commercial |
$21.87
|
| Rate for Payer: Humana KY Medicaid |
$8.85
|
| Rate for Payer: Kentucky WC Medicaid |
$8.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.64
|
| Rate for Payer: Ohio Health Group HMO |
$19.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.98
|
| Rate for Payer: PHCS Commercial |
$24.70
|
| Rate for Payer: United Healthcare All Payer |
$22.64
|
| Rate for Payer: Aetna Commercial |
$19.81
|
|
|
GABITRIL 12MG TAB
|
Facility
|
IP
|
$25.73
|
|
|
Service Code
|
NDC 93807256
|
| Hospital Charge Code |
25000708
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$19.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.07
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna Commercial |
$21.36
|
| Rate for Payer: First Health Commercial |
$24.44
|
| Rate for Payer: Humana Commercial |
$21.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.64
|
| Rate for Payer: Ohio Health Group HMO |
$19.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.98
|
| Rate for Payer: PHCS Commercial |
$24.70
|
| Rate for Payer: United Healthcare All Payer |
$22.64
|
|
|
GABITRIL 16MG TAB
|
Facility
|
IP
|
$28.43
|
|
|
Service Code
|
NDC 93807656
|
| Hospital Charge Code |
25000709
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Aetna Commercial |
$21.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.18
|
| Rate for Payer: Cash Price |
$14.21
|
| Rate for Payer: Cigna Commercial |
$23.60
|
| Rate for Payer: First Health Commercial |
$27.01
|
| Rate for Payer: Humana Commercial |
$24.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.02
|
| Rate for Payer: Ohio Health Group HMO |
$21.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.81
|
| Rate for Payer: PHCS Commercial |
$27.29
|
| Rate for Payer: United Healthcare All Payer |
$25.02
|
|
|
GABITRIL 16MG TAB
|
Facility
|
OP
|
$28.43
|
|
|
Service Code
|
NDC 93807656
|
| Hospital Charge Code |
25000709
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Aetna Commercial |
$21.89
|
| Rate for Payer: Anthem Medicaid |
$9.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.18
|
| Rate for Payer: Cash Price |
$14.21
|
| Rate for Payer: Cigna Commercial |
$23.60
|
| Rate for Payer: First Health Commercial |
$27.01
|
| Rate for Payer: Humana Commercial |
$24.17
|
| Rate for Payer: Humana KY Medicaid |
$9.78
|
| Rate for Payer: Kentucky WC Medicaid |
$9.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.02
|
| Rate for Payer: Ohio Health Group HMO |
$21.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.81
|
| Rate for Payer: PHCS Commercial |
$27.29
|
| Rate for Payer: United Healthcare All Payer |
$25.02
|
|
|
GABITRIL (TIAGABINE) 2MG TAB
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
NDC 62756020083
|
| Hospital Charge Code |
25000706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem Medicaid |
$8.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Humana KY Medicaid |
$8.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.24
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GABITRIL (TIAGABINE) 2MG TAB
|
Facility
|
IP
|
$23.35
|
|
|
Service Code
|
NDC 62756020083
|
| Hospital Charge Code |
25000706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.24
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GABITRIL (TIAGABINE) 4MG
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
NDC 62756022483
|
| Hospital Charge Code |
25000707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem Medicaid |
$8.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Humana KY Medicaid |
$8.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.24
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GABITRIL (TIAGABINE) 4MG
|
Facility
|
IP
|
$23.35
|
|
|
Service Code
|
NDC 62756022483
|
| Hospital Charge Code |
25000707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.24
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GAIT TR INC STAIRS - 15 MIN
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 97116
|
| Hospital Charge Code |
42000020
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$13.91 |
| Max. Negotiated Rate |
$102.72 |
| Rate for Payer: Aetna Commercial |
$82.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.46
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$88.81
|
| Rate for Payer: First Health Commercial |
$101.65
|
| Rate for Payer: Humana Commercial |
$90.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.16
|
| Rate for Payer: Ohio Health Group HMO |
$80.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.17
|
| Rate for Payer: PHCS Commercial |
$102.72
|
| Rate for Payer: United Healthcare All Payer |
$94.16
|
|
|
GAIT TR INC STAIRS - 15 MIN
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 97116
|
| Hospital Charge Code |
42000020
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$13.91 |
| Max. Negotiated Rate |
$102.72 |
| Rate for Payer: Aetna Commercial |
$82.39
|
| Rate for Payer: Anthem Medicaid |
$36.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.46
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$88.81
|
| Rate for Payer: First Health Commercial |
$101.65
|
| Rate for Payer: Humana Commercial |
$90.95
|
| Rate for Payer: Humana KY Medicaid |
$36.80
|
| Rate for Payer: Kentucky WC Medicaid |
$37.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.16
|
| Rate for Payer: Ohio Health Group HMO |
$80.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.17
|
| Rate for Payer: PHCS Commercial |
$102.72
|
| Rate for Payer: United Healthcare All Payer |
$94.16
|
|
|
GALACTOSE-ALPHA-1 3-GALCT IGE
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30001798
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$105.60 |
| Rate for Payer: Aetna Commercial |
$84.70
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.33
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$91.30
|
| Rate for Payer: First Health Commercial |
$104.50
|
| Rate for Payer: Humana Commercial |
$93.50
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$90.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$81.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$96.80
|
| Rate for Payer: Ohio Health Group HMO |
$82.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.10
|
| Rate for Payer: PHCS Commercial |
$105.60
|
| Rate for Payer: United Healthcare All Payer |
$96.80
|
|
|
GALACTOSE-ALPHA-1 3-GALCT IGE
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30001798
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$105.60 |
| Rate for Payer: Aetna Commercial |
$84.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.33
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$91.30
|
| Rate for Payer: First Health Commercial |
$104.50
|
| Rate for Payer: Humana Commercial |
$93.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$90.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$81.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$96.80
|
| Rate for Payer: Ohio Health Group HMO |
$82.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.10
|
| Rate for Payer: PHCS Commercial |
$105.60
|
| Rate for Payer: United Healthcare All Payer |
$96.80
|
|
