|
WRINKLE + TEXTURE REPAIR 1 OZ
|
Professional
|
Both
|
$90.00
|
|
| Hospital Charge Code |
22200163
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$90.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Multiplan PHCS |
$54.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.00
|
| Rate for Payer: UHCCP Medicaid |
$31.50
|
|
|
WRIST FUNSION PLATE REAMR HEAD
|
Facility
|
IP
|
$3,516.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$457.08 |
| Max. Negotiated Rate |
$3,375.36 |
| Rate for Payer: Aetna Commercial |
$2,707.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,742.48
|
| Rate for Payer: Cash Price |
$1,758.00
|
| Rate for Payer: Cigna Commercial |
$2,918.28
|
| Rate for Payer: First Health Commercial |
$3,340.20
|
| Rate for Payer: Humana Commercial |
$2,988.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,883.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,594.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,054.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,094.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,637.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$703.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$457.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,089.96
|
| Rate for Payer: PHCS Commercial |
$3,375.36
|
| Rate for Payer: United Healthcare All Payer |
$3,094.08
|
|
|
WRIST FUNSION PLATE REAMR HEAD
|
Facility
|
OP
|
$3,516.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$457.08 |
| Max. Negotiated Rate |
$3,375.36 |
| Rate for Payer: Humana Commercial |
$2,988.60
|
| Rate for Payer: Humana KY Medicaid |
$1,209.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1,221.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,883.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,594.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,054.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,233.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,094.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,637.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$703.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$457.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,089.96
|
| Rate for Payer: PHCS Commercial |
$3,375.36
|
| Rate for Payer: United Healthcare All Payer |
$3,094.08
|
| Rate for Payer: Aetna Commercial |
$2,707.32
|
| Rate for Payer: Anthem Medicaid |
$1,209.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,742.48
|
| Rate for Payer: Cash Price |
$1,758.00
|
| Rate for Payer: Cigna Commercial |
$2,918.28
|
| Rate for Payer: First Health Commercial |
$3,340.20
|
|
|
WRIST LT 3V
|
Professional
|
Both
|
$442.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
32000085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$442.00 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: Anthem Medicaid |
$21.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$442.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$45.59
|
| Rate for Payer: Healthspan PPO |
$47.31
|
| Rate for Payer: Humana Medicaid |
$21.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.23
|
| Rate for Payer: Molina Healthcare Passport |
$21.79
|
| Rate for Payer: Multiplan PHCS |
$265.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$309.40
|
| Rate for Payer: UHCCP Medicaid |
$154.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.01
|
|
|
WRIST LT 3V
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
32000085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.46 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.02
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
WRIST LT 3V
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
32000085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.46 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$152.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$152.00
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$153.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$155.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.02
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
WRIST LT 3V(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
320P0085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$50.49 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: Anthem Medicaid |
$21.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$45.59
|
| Rate for Payer: Healthspan PPO |
$47.31
|
| Rate for Payer: Humana Medicaid |
$21.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.23
|
| Rate for Payer: Molina Healthcare Passport |
$21.79
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.01
|
|
|
WRIST LT 3V(T
|
Facility
|
OP
|
$402.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
320T0085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.26 |
| Max. Negotiated Rate |
$385.92 |
| Rate for Payer: Aetna Commercial |
$309.54
|
| Rate for Payer: Anthem Medicaid |
$138.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$313.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$333.66
|
| Rate for Payer: First Health Commercial |
$381.90
|
| Rate for Payer: Humana Commercial |
$341.70
|
| Rate for Payer: Humana KY Medicaid |
$138.25
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$139.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$329.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$296.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$141.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$353.76
|
| Rate for Payer: Ohio Health Group HMO |
$301.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.62
|
| Rate for Payer: PHCS Commercial |
$385.92
|
| Rate for Payer: United Healthcare All Payer |
$353.76
|
|
|
WRIST LT 3V(T
|
Facility
|
IP
|
$402.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
320T0085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.26 |
| Max. Negotiated Rate |
$385.92 |
| Rate for Payer: Aetna Commercial |
$309.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$313.56
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$333.66
|
| Rate for Payer: First Health Commercial |
$381.90
|
| Rate for Payer: Humana Commercial |
$341.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$329.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$296.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$353.76
|
| Rate for Payer: Ohio Health Group HMO |
$301.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.62
|
| Rate for Payer: PHCS Commercial |
$385.92
|
| Rate for Payer: United Healthcare All Payer |
$353.76
|
|
|
XALATAN (LATANOPROST) ML/2.5ML
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
25001722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.84
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna Commercial |
$0.90
|
| Rate for Payer: First Health Commercial |
$1.03
|
| Rate for Payer: Humana Commercial |
$0.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.95
|
| Rate for Payer: Ohio Health Group HMO |
$0.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.33
|
| Rate for Payer: PHCS Commercial |
$1.04
|
| Rate for Payer: United Healthcare All Payer |
$0.95
|
|
|
XALATAN (LATANOPROST) ML/2.5ML
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
25001722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.83
|
| Rate for Payer: Anthem Medicaid |
$0.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.84
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna Commercial |
$0.90
|
| Rate for Payer: First Health Commercial |
$1.03
|
| Rate for Payer: Humana Commercial |
$0.92
|
| Rate for Payer: Humana KY Medicaid |
$0.37
|
| Rate for Payer: Kentucky WC Medicaid |
$0.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.95
|
| Rate for Payer: Ohio Health Group HMO |
$0.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.33
|
| Rate for Payer: PHCS Commercial |
$1.04
|
| Rate for Payer: United Healthcare All Payer |
$0.95
|
|
|
XARELTO 10MG TABLET
|
Facility
|
IP
|
$35.99
|
|
|
Service Code
|
NDC 50458058010
|
| Hospital Charge Code |
25001727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.87
|
| Rate for Payer: First Health Commercial |
$34.19
|
| Rate for Payer: Humana Commercial |
$30.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.16
|
| Rate for Payer: PHCS Commercial |
$34.55
|
| Rate for Payer: United Healthcare All Payer |
$31.67
|
|
|
XARELTO 10MG TABLET
|
Facility
|
OP
|
$35.99
|
|
|
Service Code
|
NDC 50458058010
|
| Hospital Charge Code |
25001727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.87
|
| Rate for Payer: First Health Commercial |
$34.19
|
| Rate for Payer: Humana Commercial |
$30.59
|
| Rate for Payer: Humana KY Medicaid |
$12.38
|
| Rate for Payer: Kentucky WC Medicaid |
$12.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.16
|
| Rate for Payer: PHCS Commercial |
$34.55
|
| Rate for Payer: United Healthcare All Payer |
$31.67
|
|
|
XARELTO 15 MG TABLET
|
Facility
|
OP
|
$35.99
|
|
|
Service Code
|
NDC 50458057810
|
| Hospital Charge Code |
25001728
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.87
|
| Rate for Payer: First Health Commercial |
$34.19
|
| Rate for Payer: Humana Commercial |
$30.59
|
| Rate for Payer: Humana KY Medicaid |
$12.38
|
| Rate for Payer: Kentucky WC Medicaid |
$12.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.16
|
| Rate for Payer: PHCS Commercial |
$34.55
|
| Rate for Payer: United Healthcare All Payer |
$31.67
|
|
|
XARELTO 15 MG TABLET
|
Facility
|
IP
|
$35.99
|
|
|
Service Code
|
NDC 50458057810
|
| Hospital Charge Code |
25001728
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.87
|
| Rate for Payer: First Health Commercial |
$34.19
|
| Rate for Payer: Humana Commercial |
$30.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.16
|
| Rate for Payer: PHCS Commercial |
$34.55
|
| Rate for Payer: United Healthcare All Payer |
$31.67
|
|
|
XARELTO 20MG TABLET
|
Facility
|
IP
|
$35.99
|
|
|
Service Code
|
NDC 50458057910
|
| Hospital Charge Code |
25001729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.87
|
| Rate for Payer: First Health Commercial |
$34.19
|
| Rate for Payer: Humana Commercial |
$30.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.16
|
| Rate for Payer: PHCS Commercial |
$34.55
|
| Rate for Payer: United Healthcare All Payer |
$31.67
|
|
|
XARELTO 20MG TABLET
|
Facility
|
OP
|
$35.99
|
|
|
Service Code
|
NDC 50458057910
|
| Hospital Charge Code |
25001729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.87
|
| Rate for Payer: First Health Commercial |
$34.19
|
| Rate for Payer: Humana Commercial |
$30.59
|
| Rate for Payer: Humana KY Medicaid |
$12.38
|
| Rate for Payer: Kentucky WC Medicaid |
$12.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.16
|
| Rate for Payer: PHCS Commercial |
$34.55
|
| Rate for Payer: United Healthcare All Payer |
$31.67
|
|
|
XARELTO 2.5 MG TABLET
|
Facility
|
OP
|
$26.49
|
|
|
Service Code
|
NDC 50458057760
|
| Hospital Charge Code |
25003871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$25.43 |
| Rate for Payer: Aetna Commercial |
$20.40
|
| Rate for Payer: Anthem Medicaid |
$9.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Cash Price |
$13.24
|
| Rate for Payer: Cigna Commercial |
$21.99
|
| Rate for Payer: First Health Commercial |
$25.17
|
| Rate for Payer: Humana Commercial |
$22.52
|
| Rate for Payer: Humana KY Medicaid |
$9.11
|
| Rate for Payer: Kentucky WC Medicaid |
$9.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.31
|
| Rate for Payer: Ohio Health Group HMO |
$19.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.21
|
| Rate for Payer: PHCS Commercial |
$25.43
|
| Rate for Payer: United Healthcare All Payer |
$23.31
|
|
|
XARELTO 2.5 MG TABLET
|
Facility
|
IP
|
$26.49
|
|
|
Service Code
|
NDC 50458057760
|
| Hospital Charge Code |
25003871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$25.43 |
| Rate for Payer: Aetna Commercial |
$20.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Cash Price |
$13.24
|
| Rate for Payer: Cigna Commercial |
$21.99
|
| Rate for Payer: First Health Commercial |
$25.17
|
| Rate for Payer: Humana Commercial |
$22.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.31
|
| Rate for Payer: Ohio Health Group HMO |
$19.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.21
|
| Rate for Payer: PHCS Commercial |
$25.43
|
| Rate for Payer: United Healthcare All Payer |
$23.31
|
|
|
XELODA (50MG)150MG TABLET
|
Facility
|
IP
|
$73.90
|
|
|
Service Code
|
HCPCS J8522
|
| Hospital Charge Code |
25002533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$70.94 |
| Rate for Payer: Aetna Commercial |
$56.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Cash Price |
$36.95
|
| Rate for Payer: Cigna Commercial |
$61.34
|
| Rate for Payer: First Health Commercial |
$70.20
|
| Rate for Payer: Humana Commercial |
$62.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.03
|
| Rate for Payer: Ohio Health Group HMO |
$55.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.91
|
| Rate for Payer: PHCS Commercial |
$70.94
|
| Rate for Payer: United Healthcare All Payer |
$65.03
|
|
|
XELODA (50MG)150MG TABLET
|
Facility
|
OP
|
$73.90
|
|
|
Service Code
|
HCPCS J8522
|
| Hospital Charge Code |
25002533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$70.94 |
| Rate for Payer: Aetna Commercial |
$56.90
|
| Rate for Payer: Anthem Medicaid |
$25.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Cash Price |
$36.95
|
| Rate for Payer: Cigna Commercial |
$61.34
|
| Rate for Payer: First Health Commercial |
$70.20
|
| Rate for Payer: Humana Commercial |
$62.82
|
| Rate for Payer: Humana KY Medicaid |
$25.41
|
| Rate for Payer: Kentucky WC Medicaid |
$25.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.03
|
| Rate for Payer: Ohio Health Group HMO |
$55.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.91
|
| Rate for Payer: PHCS Commercial |
$70.94
|
| Rate for Payer: United Healthcare All Payer |
$65.03
|
|
|
XELODA (50MG)500MG TABLET
|
Facility
|
OP
|
$246.29
|
|
|
Service Code
|
HCPCS J8522
|
| Hospital Charge Code |
25002534
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.02 |
| Max. Negotiated Rate |
$236.44 |
| Rate for Payer: Aetna Commercial |
$189.64
|
| Rate for Payer: Anthem Medicaid |
$84.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.11
|
| Rate for Payer: Cash Price |
$123.14
|
| Rate for Payer: Cigna Commercial |
$204.42
|
| Rate for Payer: First Health Commercial |
$233.98
|
| Rate for Payer: Humana Commercial |
$209.35
|
| Rate for Payer: Humana KY Medicaid |
$84.70
|
| Rate for Payer: Kentucky WC Medicaid |
$85.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$201.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$181.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$86.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$216.74
|
| Rate for Payer: Ohio Health Group HMO |
$184.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.35
|
| Rate for Payer: PHCS Commercial |
$236.44
|
| Rate for Payer: United Healthcare All Payer |
$216.74
|
|
|
XELODA (50MG)500MG TABLET
|
Facility
|
IP
|
$246.29
|
|
|
Service Code
|
HCPCS J8522
|
| Hospital Charge Code |
25002534
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.02 |
| Max. Negotiated Rate |
$236.44 |
| Rate for Payer: Aetna Commercial |
$189.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.11
|
| Rate for Payer: Cash Price |
$123.14
|
| Rate for Payer: Cigna Commercial |
$204.42
|
| Rate for Payer: First Health Commercial |
$233.98
|
| Rate for Payer: Humana Commercial |
$209.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$201.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$181.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$216.74
|
| Rate for Payer: Ohio Health Group HMO |
$184.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.35
|
| Rate for Payer: PHCS Commercial |
$236.44
|
| Rate for Payer: United Healthcare All Payer |
$216.74
|
|
|
XEN® 45 GEL STENT—GLAUCOMA DEV
|
Facility
|
OP
|
$10,782.50
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
27000084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,401.72 |
| Max. Negotiated Rate |
$10,351.20 |
| Rate for Payer: Aetna Commercial |
$8,302.52
|
| Rate for Payer: Anthem Medicaid |
$3,708.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,410.35
|
| Rate for Payer: Cash Price |
$5,391.25
|
| Rate for Payer: Cigna Commercial |
$8,949.48
|
| Rate for Payer: First Health Commercial |
$10,243.38
|
| Rate for Payer: Humana Commercial |
$9,165.12
|
| Rate for Payer: Humana KY Medicaid |
$3,708.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,745.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,841.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,957.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,234.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,782.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,488.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,086.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,156.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,401.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,342.58
|
| Rate for Payer: PHCS Commercial |
$10,351.20
|
| Rate for Payer: United Healthcare All Payer |
$9,488.60
|
|
|
XEN® 45 GEL STENT—GLAUCOMA DEV
|
Facility
|
IP
|
$10,782.50
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
27000084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,401.72 |
| Max. Negotiated Rate |
$10,351.20 |
| Rate for Payer: Aetna Commercial |
$8,302.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,410.35
|
| Rate for Payer: Cash Price |
$5,391.25
|
| Rate for Payer: Cigna Commercial |
$8,949.48
|
| Rate for Payer: First Health Commercial |
$10,243.38
|
| Rate for Payer: Humana Commercial |
$9,165.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,841.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,957.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,234.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,488.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,086.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,156.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,401.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,342.58
|
| Rate for Payer: PHCS Commercial |
$10,351.20
|
| Rate for Payer: United Healthcare All Payer |
$9,488.60
|
|
