|
TAP BLOCK UNIL BY INJECTION(T
|
Facility
|
IP
|
$2,395.98
|
|
|
Service Code
|
HCPCS 64486
|
| Hospital Charge Code |
761T2325
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$718.79 |
| Max. Negotiated Rate |
$2,300.14 |
| Rate for Payer: Aetna Commercial |
$1,844.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,868.86
|
| Rate for Payer: Cash Price |
$1,197.99
|
| Rate for Payer: Cigna Commercial |
$1,988.66
|
| Rate for Payer: First Health Commercial |
$2,276.18
|
| Rate for Payer: Humana Commercial |
$2,036.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,964.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,768.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$718.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,108.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,796.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,916.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,084.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.23
|
| Rate for Payer: PHCS Commercial |
$2,300.14
|
| Rate for Payer: United Healthcare All Payer |
$2,108.46
|
|
|
TAP BLOCK UNIL BY INJECTION(T
|
Facility
|
OP
|
$2,395.98
|
|
|
Service Code
|
HCPCS 64486
|
| Hospital Charge Code |
761T2325
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$718.79 |
| Max. Negotiated Rate |
$2,300.14 |
| Rate for Payer: Aetna Commercial |
$1,844.90
|
| Rate for Payer: Anthem Medicaid |
$823.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,868.86
|
| Rate for Payer: Cash Price |
$1,197.99
|
| Rate for Payer: Cigna Commercial |
$1,988.66
|
| Rate for Payer: First Health Commercial |
$2,276.18
|
| Rate for Payer: Humana Commercial |
$2,036.58
|
| Rate for Payer: Humana KY Medicaid |
$823.98
|
| Rate for Payer: Kentucky WC Medicaid |
$832.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,964.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,768.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$718.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$840.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,108.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,796.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,916.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,084.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.23
|
| Rate for Payer: PHCS Commercial |
$2,300.14
|
| Rate for Payer: United Healthcare All Payer |
$2,108.46
|
|
|
TAPERLOC FEM STEM 10MMX140
|
Facility
|
IP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
TAPERLOC FEM STEM 10MMX140
|
Facility
|
OP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem Medicaid |
$7,914.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Humana KY Medicaid |
$7,914.86
|
| Rate for Payer: Kentucky WC Medicaid |
$7,995.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,073.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
TAPERLOC POR FMRLSTEM 13.5X147
|
Facility
|
OP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem Medicaid |
$7,914.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Humana KY Medicaid |
$7,914.86
|
| Rate for Payer: Kentucky WC Medicaid |
$7,995.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,073.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
TAPERLOC POR FMRLSTEM 13.5X147
|
Facility
|
IP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
TAPER POST 8.0MM
|
Facility
|
IP
|
$3,481.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.38 |
| Max. Negotiated Rate |
$3,342.00 |
| Rate for Payer: Aetna Commercial |
$2,680.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,715.38
|
| Rate for Payer: Cash Price |
$1,740.62
|
| Rate for Payer: Cigna Commercial |
$2,889.44
|
| Rate for Payer: First Health Commercial |
$3,307.19
|
| Rate for Payer: Humana Commercial |
$2,959.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,854.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,569.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,044.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,063.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,610.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,785.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,402.06
|
| Rate for Payer: PHCS Commercial |
$3,342.00
|
| Rate for Payer: United Healthcare All Payer |
$3,063.50
|
|
|
TAPER POST 8.0MM
|
Facility
|
OP
|
$3,481.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.38 |
| Max. Negotiated Rate |
$3,342.00 |
| Rate for Payer: Aetna Commercial |
$2,680.56
|
| Rate for Payer: Anthem Medicaid |
$1,197.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,715.38
|
| Rate for Payer: Cash Price |
$1,740.62
|
| Rate for Payer: Cigna Commercial |
$2,889.44
|
| Rate for Payer: First Health Commercial |
$3,307.19
|
| Rate for Payer: Humana Commercial |
$2,959.06
|
| Rate for Payer: Humana KY Medicaid |
$1,197.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,209.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,854.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,569.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,044.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,221.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,063.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,610.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,785.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,402.06
|
| Rate for Payer: PHCS Commercial |
$3,342.00
|
| Rate for Payer: United Healthcare All Payer |
$3,063.50
|
|
|
TAPER POST 9.5MM
|
Facility
|
IP
|
$3,481.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.38 |
| Max. Negotiated Rate |
$3,342.00 |
| Rate for Payer: Aetna Commercial |
$2,680.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,715.38
|
| Rate for Payer: Cash Price |
$1,740.62
|
| Rate for Payer: Cigna Commercial |
$2,889.44
|
| Rate for Payer: First Health Commercial |
$3,307.19
|
| Rate for Payer: Humana Commercial |
$2,959.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,854.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,569.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,044.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,063.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,610.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,785.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,402.06
|
| Rate for Payer: PHCS Commercial |
$3,342.00
|
| Rate for Payer: United Healthcare All Payer |
$3,063.50
|
|
|
TAPER POST 9.5MM
|
Facility
|
OP
|
$3,481.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.38 |
| Max. Negotiated Rate |
$3,342.00 |
| Rate for Payer: Aetna Commercial |
$2,680.56
|
| Rate for Payer: Anthem Medicaid |
$1,197.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,715.38
|
| Rate for Payer: Cash Price |
$1,740.62
|
| Rate for Payer: Cigna Commercial |
$2,889.44
|
| Rate for Payer: First Health Commercial |
$3,307.19
|
| Rate for Payer: Humana Commercial |
$2,959.06
|
| Rate for Payer: Humana KY Medicaid |
$1,197.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,209.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,854.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,569.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,044.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,221.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,063.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,610.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,785.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,402.06
|
| Rate for Payer: PHCS Commercial |
$3,342.00
|
| Rate for Payer: United Healthcare All Payer |
$3,063.50
|
|
|
TARCEVA (ERLOTINIB) 100MG
|
Facility
|
OP
|
$1,357.43
|
|
|
Service Code
|
NDC 50242006301
|
| Hospital Charge Code |
25003513
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$407.23 |
| Max. Negotiated Rate |
$1,303.13 |
| Rate for Payer: Aetna Commercial |
$1,045.22
|
| Rate for Payer: Anthem Medicaid |
$466.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,058.80
|
| Rate for Payer: Cash Price |
$678.72
|
| Rate for Payer: Cigna Commercial |
$1,126.67
|
| Rate for Payer: First Health Commercial |
$1,289.56
|
| Rate for Payer: Humana Commercial |
$1,153.82
|
| Rate for Payer: Humana KY Medicaid |
$466.82
|
| Rate for Payer: Kentucky WC Medicaid |
$471.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,113.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,001.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$407.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$476.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,194.54
|
| Rate for Payer: Ohio Health Group HMO |
$1,018.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,085.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,180.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.63
|
| Rate for Payer: PHCS Commercial |
$1,303.13
|
| Rate for Payer: United Healthcare All Payer |
$1,194.54
|
|
|
TARCEVA (ERLOTINIB) 100MG
|
Facility
|
IP
|
$1,357.43
|
|
|
Service Code
|
NDC 50242006301
|
| Hospital Charge Code |
25003513
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$407.23 |
| Max. Negotiated Rate |
$1,303.13 |
| Rate for Payer: Aetna Commercial |
$1,045.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,058.80
|
| Rate for Payer: Cash Price |
$678.72
|
| Rate for Payer: Cigna Commercial |
$1,126.67
|
| Rate for Payer: First Health Commercial |
$1,289.56
|
| Rate for Payer: Humana Commercial |
$1,153.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,113.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,001.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$407.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,194.54
|
| Rate for Payer: Ohio Health Group HMO |
$1,018.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,085.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,180.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.63
|
| Rate for Payer: PHCS Commercial |
$1,303.13
|
| Rate for Payer: United Healthcare All Payer |
$1,194.54
|
|
|
TARCEVA(ERLOTINIB) 150 MG
|
Facility
|
OP
|
$1,535.32
|
|
|
Service Code
|
NDC 50242006401
|
| Hospital Charge Code |
25003514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$1,473.91 |
| Rate for Payer: Aetna Commercial |
$1,182.20
|
| Rate for Payer: Anthem Medicaid |
$528.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,197.55
|
| Rate for Payer: Cash Price |
$767.66
|
| Rate for Payer: Cigna Commercial |
$1,274.32
|
| Rate for Payer: First Health Commercial |
$1,458.55
|
| Rate for Payer: Humana Commercial |
$1,305.02
|
| Rate for Payer: Humana KY Medicaid |
$528.00
|
| Rate for Payer: Kentucky WC Medicaid |
$533.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,258.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,133.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$460.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$538.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,351.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,151.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,228.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,335.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,059.37
|
| Rate for Payer: PHCS Commercial |
$1,473.91
|
| Rate for Payer: United Healthcare All Payer |
$1,351.08
|
|
|
TARCEVA(ERLOTINIB) 150 MG
|
Facility
|
IP
|
$1,535.32
|
|
|
Service Code
|
NDC 50242006401
|
| Hospital Charge Code |
25003514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$1,473.91 |
| Rate for Payer: Aetna Commercial |
$1,182.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,197.55
|
| Rate for Payer: Cash Price |
$767.66
|
| Rate for Payer: Cigna Commercial |
$1,274.32
|
| Rate for Payer: First Health Commercial |
$1,458.55
|
| Rate for Payer: Humana Commercial |
$1,305.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,258.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,133.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$460.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,351.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,151.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,228.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,335.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,059.37
|
| Rate for Payer: PHCS Commercial |
$1,473.91
|
| Rate for Payer: United Healthcare All Payer |
$1,351.08
|
|
|
TARCEVA (ERLOTINIB) 25MG TAB
|
Facility
|
IP
|
$494.21
|
|
|
Service Code
|
NDC 50242006201
|
| Hospital Charge Code |
25001490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.26 |
| Max. Negotiated Rate |
$474.44 |
| Rate for Payer: Aetna Commercial |
$380.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$385.48
|
| Rate for Payer: Cash Price |
$247.10
|
| Rate for Payer: Cigna Commercial |
$410.19
|
| Rate for Payer: First Health Commercial |
$469.50
|
| Rate for Payer: Humana Commercial |
$420.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$364.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$434.90
|
| Rate for Payer: Ohio Health Group HMO |
$370.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$395.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$429.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$474.44
|
| Rate for Payer: United Healthcare All Payer |
$434.90
|
|
|
TARCEVA (ERLOTINIB) 25MG TAB
|
Facility
|
OP
|
$494.21
|
|
|
Service Code
|
NDC 50242006201
|
| Hospital Charge Code |
25001490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.26 |
| Max. Negotiated Rate |
$474.44 |
| Rate for Payer: Aetna Commercial |
$380.54
|
| Rate for Payer: Anthem Medicaid |
$169.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$385.48
|
| Rate for Payer: Cash Price |
$247.10
|
| Rate for Payer: Cigna Commercial |
$410.19
|
| Rate for Payer: First Health Commercial |
$469.50
|
| Rate for Payer: Humana Commercial |
$420.08
|
| Rate for Payer: Humana KY Medicaid |
$169.96
|
| Rate for Payer: Kentucky WC Medicaid |
$171.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$364.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$173.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$434.90
|
| Rate for Payer: Ohio Health Group HMO |
$370.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$395.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$429.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$474.44
|
| Rate for Payer: United Healthcare All Payer |
$434.90
|
|
|
TARSAL FX(NOTTALUSCALCAN)WMAN
|
Facility
|
IP
|
$580.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
76101017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$556.80 |
| Rate for Payer: Aetna Commercial |
$446.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$452.40
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$481.40
|
| Rate for Payer: First Health Commercial |
$551.00
|
| Rate for Payer: Humana Commercial |
$493.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$475.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$510.40
|
| Rate for Payer: Ohio Health Group HMO |
$435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$504.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.20
|
| Rate for Payer: PHCS Commercial |
$556.80
|
| Rate for Payer: United Healthcare All Payer |
$510.40
|
|
|
TARSAL FX(NOTTALUSCALCAN)WMAN
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
45000177
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$725.97 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem Medicaid |
$725.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Humana KY Medicaid |
$725.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$733.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$740.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
TARSAL FX(NOTTALUSCALCAN)WMAN
|
Facility
|
OP
|
$580.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
76101017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$199.46 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$446.60
|
| Rate for Payer: Anthem Medicaid |
$199.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$452.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$481.40
|
| Rate for Payer: First Health Commercial |
$551.00
|
| Rate for Payer: Humana Commercial |
$493.00
|
| Rate for Payer: Humana KY Medicaid |
$199.46
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$201.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$475.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$203.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$510.40
|
| Rate for Payer: Ohio Health Group HMO |
$435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$504.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.20
|
| Rate for Payer: PHCS Commercial |
$556.80
|
| Rate for Payer: United Healthcare All Payer |
$510.40
|
|
|
TARSAL FX(NOTTALUSCALCAN)WMAN
|
Professional
|
Both
|
$580.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
76101017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$148.50 |
| Max. Negotiated Rate |
$424.64 |
| Rate for Payer: Aetna Commercial |
$380.15
|
| Rate for Payer: Ambetter Exchange |
$219.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$148.50
|
| Rate for Payer: Anthem Medicaid |
$162.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$219.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$219.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$263.09
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$424.64
|
| Rate for Payer: Healthspan PPO |
$366.63
|
| Rate for Payer: Humana Medicaid |
$162.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$322.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$219.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$219.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$165.91
|
| Rate for Payer: Molina Healthcare Passport |
$162.66
|
| Rate for Payer: Multiplan PHCS |
$348.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$285.01
|
| Rate for Payer: UHCCP Medicaid |
$155.93
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$219.24
|
|
|
TARSAL FX(NOTTALUSCALCAN)WMAN
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
45000177
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$633.30 |
| Max. Negotiated Rate |
$2,026.56 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
TARSAL FX(NOTTALUSCALCAN)WMA(P
|
Professional
|
Both
|
$580.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
761P1017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$148.50 |
| Max. Negotiated Rate |
$424.64 |
| Rate for Payer: Aetna Commercial |
$380.15
|
| Rate for Payer: Ambetter Exchange |
$219.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$148.50
|
| Rate for Payer: Anthem Medicaid |
$162.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$219.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$219.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$263.09
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$424.64
|
| Rate for Payer: Healthspan PPO |
$366.63
|
| Rate for Payer: Humana Medicaid |
$162.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$322.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$219.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$219.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$165.91
|
| Rate for Payer: Molina Healthcare Passport |
$162.66
|
| Rate for Payer: Multiplan PHCS |
$348.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$285.01
|
| Rate for Payer: UHCCP Medicaid |
$155.93
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$219.24
|
|
|
TASMAR (TOLCAPONE) 100MG TAB
|
Facility
|
IP
|
$288.54
|
|
|
Service Code
|
NDC 187093801
|
| Hospital Charge Code |
25001493
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.56 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$222.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$225.06
|
| Rate for Payer: Cash Price |
$144.27
|
| Rate for Payer: Cigna Commercial |
$239.49
|
| Rate for Payer: First Health Commercial |
$274.11
|
| Rate for Payer: Humana Commercial |
$245.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$236.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.92
|
| Rate for Payer: Ohio Health Group HMO |
$216.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$199.09
|
| Rate for Payer: PHCS Commercial |
$277.00
|
| Rate for Payer: United Healthcare All Payer |
$253.92
|
|
|
TASMAR (TOLCAPONE) 100MG TAB
|
Facility
|
OP
|
$288.54
|
|
|
Service Code
|
NDC 187093801
|
| Hospital Charge Code |
25001493
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.56 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$222.18
|
| Rate for Payer: Anthem Medicaid |
$99.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$225.06
|
| Rate for Payer: Cash Price |
$144.27
|
| Rate for Payer: Cigna Commercial |
$239.49
|
| Rate for Payer: First Health Commercial |
$274.11
|
| Rate for Payer: Humana Commercial |
$245.26
|
| Rate for Payer: Humana KY Medicaid |
$99.23
|
| Rate for Payer: Kentucky WC Medicaid |
$100.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$236.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$101.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.92
|
| Rate for Payer: Ohio Health Group HMO |
$216.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$199.09
|
| Rate for Payer: PHCS Commercial |
$277.00
|
| Rate for Payer: United Healthcare All Payer |
$253.92
|
|
|
TAXOTERE 1MG (20MG VL)
|
Facility
|
IP
|
$594.05
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
25002603
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.22 |
| Max. Negotiated Rate |
$570.29 |
| Rate for Payer: Aetna Commercial |
$457.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$463.36
|
| Rate for Payer: Cash Price |
$297.02
|
| Rate for Payer: Cigna Commercial |
$493.06
|
| Rate for Payer: First Health Commercial |
$564.35
|
| Rate for Payer: Humana Commercial |
$504.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$438.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$522.76
|
| Rate for Payer: Ohio Health Group HMO |
$445.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$475.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$409.89
|
| Rate for Payer: PHCS Commercial |
$570.29
|
| Rate for Payer: United Healthcare All Payer |
$522.76
|
|
