|
X-FUSE TRIAL LARGE 25 DEG
|
Facility
|
IP
|
$1,808.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.10 |
| Max. Negotiated Rate |
$1,736.16 |
| Rate for Payer: Aetna Commercial |
$1,392.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.63
|
| Rate for Payer: Cash Price |
$904.25
|
| Rate for Payer: Cigna Commercial |
$1,501.06
|
| Rate for Payer: First Health Commercial |
$1,718.08
|
| Rate for Payer: Humana Commercial |
$1,537.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,356.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.64
|
| Rate for Payer: PHCS Commercial |
$1,736.16
|
| Rate for Payer: United Healthcare All Payer |
$1,591.48
|
|
|
X-FUSE TRIAL LARGE 25 DEG
|
Facility
|
OP
|
$1,808.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.10 |
| Max. Negotiated Rate |
$1,736.16 |
| Rate for Payer: Aetna Commercial |
$1,392.54
|
| Rate for Payer: Anthem Medicaid |
$621.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.63
|
| Rate for Payer: Cash Price |
$904.25
|
| Rate for Payer: Cigna Commercial |
$1,501.06
|
| Rate for Payer: First Health Commercial |
$1,718.08
|
| Rate for Payer: Humana Commercial |
$1,537.22
|
| Rate for Payer: Humana KY Medicaid |
$621.94
|
| Rate for Payer: Kentucky WC Medicaid |
$628.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,356.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.64
|
| Rate for Payer: PHCS Commercial |
$1,736.16
|
| Rate for Payer: United Healthcare All Payer |
$1,591.48
|
|
|
X-FUSE TRIAL XLARGE 0 DEG
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
X-FUSE TRIAL XLARGE 0 DEG
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem Medicaid |
$623.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Humana KY Medicaid |
$623.15
|
| Rate for Payer: Kentucky WC Medicaid |
$629.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
X-FUSE TRIAL XLARGE 15 DEG
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem Medicaid |
$623.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Humana KY Medicaid |
$623.15
|
| Rate for Payer: Kentucky WC Medicaid |
$629.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
X-FUSE TRIAL XLARGE 15 DEG
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
XGEVA 1MG [120MG/1.7ML VIAL]
|
Facility
|
OP
|
$17,905.81
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
25002004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$17,189.58 |
| Rate for Payer: Aetna Commercial |
$13,787.47
|
| Rate for Payer: Anthem Medicaid |
$6,157.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,966.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.02
|
| Rate for Payer: Cash Price |
$8,952.91
|
| Rate for Payer: Cash Price |
$8,952.91
|
| Rate for Payer: Cigna Commercial |
$14,861.82
|
| Rate for Payer: First Health Commercial |
$17,010.52
|
| Rate for Payer: Humana Commercial |
$15,219.94
|
| Rate for Payer: Humana KY Medicaid |
$6,157.81
|
| Rate for Payer: Humana Medicare Advantage |
$25.20
|
| Rate for Payer: Kentucky WC Medicaid |
$6,220.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,682.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,214.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,281.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,757.11
|
| Rate for Payer: Ohio Health Group HMO |
$13,429.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,581.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,327.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,550.80
|
| Rate for Payer: PHCS Commercial |
$17,189.58
|
| Rate for Payer: United Healthcare All Payer |
$15,757.11
|
|
|
XGEVA 1MG [120MG/1.7ML VIAL]
|
Facility
|
IP
|
$17,905.81
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
25002004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,327.76 |
| Max. Negotiated Rate |
$17,189.58 |
| Rate for Payer: Aetna Commercial |
$13,787.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,966.53
|
| Rate for Payer: Cash Price |
$8,952.91
|
| Rate for Payer: Cigna Commercial |
$14,861.82
|
| Rate for Payer: First Health Commercial |
$17,010.52
|
| Rate for Payer: Humana Commercial |
$15,219.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,682.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,214.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,371.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,757.11
|
| Rate for Payer: Ohio Health Group HMO |
$13,429.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,581.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,327.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,550.80
|
| Rate for Payer: PHCS Commercial |
$17,189.58
|
| Rate for Payer: United Healthcare All Payer |
$15,757.11
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
OP
|
$35,885.09
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
25001968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$34,449.69 |
| Rate for Payer: Aetna Commercial |
$27,631.52
|
| Rate for Payer: Anthem Medicaid |
$12,340.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$66.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,990.37
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.46
|
| Rate for Payer: Cash Price |
$17,942.54
|
| Rate for Payer: Cash Price |
$17,942.54
|
| Rate for Payer: Cigna Commercial |
$29,784.62
|
| Rate for Payer: First Health Commercial |
$34,090.84
|
| Rate for Payer: Humana Commercial |
$30,502.33
|
| Rate for Payer: Humana KY Medicaid |
$12,340.88
|
| Rate for Payer: Humana Medicare Advantage |
$66.27
|
| Rate for Payer: Kentucky WC Medicaid |
$12,466.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,425.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,483.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,588.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,578.88
|
| Rate for Payer: Ohio Health Group HMO |
$26,913.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,177.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,665.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,124.38
|
| Rate for Payer: PHCS Commercial |
$34,449.69
|
| Rate for Payer: United Healthcare All Payer |
$31,578.88
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
IP
|
$369.67
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
636T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.06 |
| Max. Negotiated Rate |
$354.88 |
| Rate for Payer: Aetna Commercial |
$284.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.34
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cigna Commercial |
$306.83
|
| Rate for Payer: First Health Commercial |
$351.19
|
| Rate for Payer: Humana Commercial |
$314.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$272.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$110.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.31
|
| Rate for Payer: Ohio Health Group HMO |
$277.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.60
|
| Rate for Payer: PHCS Commercial |
$354.88
|
| Rate for Payer: United Healthcare All Payer |
$325.31
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
IP
|
$369.67
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
63600024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.06 |
| Max. Negotiated Rate |
$354.88 |
| Rate for Payer: Aetna Commercial |
$284.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.34
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cigna Commercial |
$306.83
|
| Rate for Payer: First Health Commercial |
$351.19
|
| Rate for Payer: Humana Commercial |
$314.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$272.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$110.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.31
|
| Rate for Payer: Ohio Health Group HMO |
$277.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.60
|
| Rate for Payer: PHCS Commercial |
$354.88
|
| Rate for Payer: United Healthcare All Payer |
$325.31
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
OP
|
$369.67
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
636T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.06 |
| Max. Negotiated Rate |
$354.88 |
| Rate for Payer: Aetna Commercial |
$284.65
|
| Rate for Payer: Anthem Medicaid |
$127.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$66.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.46
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cigna Commercial |
$306.83
|
| Rate for Payer: First Health Commercial |
$351.19
|
| Rate for Payer: Humana Commercial |
$314.22
|
| Rate for Payer: Humana KY Medicaid |
$127.13
|
| Rate for Payer: Humana Medicare Advantage |
$66.27
|
| Rate for Payer: Kentucky WC Medicaid |
$128.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$272.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.31
|
| Rate for Payer: Ohio Health Group HMO |
$277.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.60
|
| Rate for Payer: PHCS Commercial |
$354.88
|
| Rate for Payer: United Healthcare All Payer |
$325.31
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
IP
|
$35,885.09
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
25001968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,665.06 |
| Max. Negotiated Rate |
$34,449.69 |
| Rate for Payer: Aetna Commercial |
$27,631.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,990.37
|
| Rate for Payer: Cash Price |
$17,942.54
|
| Rate for Payer: Cigna Commercial |
$29,784.62
|
| Rate for Payer: First Health Commercial |
$34,090.84
|
| Rate for Payer: Humana Commercial |
$30,502.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,425.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,483.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,765.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,578.88
|
| Rate for Payer: Ohio Health Group HMO |
$26,913.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,177.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,665.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,124.38
|
| Rate for Payer: PHCS Commercial |
$34,449.69
|
| Rate for Payer: United Healthcare All Payer |
$31,578.88
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
OP
|
$369.67
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
63600024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.06 |
| Max. Negotiated Rate |
$354.88 |
| Rate for Payer: Aetna Commercial |
$284.65
|
| Rate for Payer: Anthem Medicaid |
$127.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$66.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.46
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cigna Commercial |
$306.83
|
| Rate for Payer: First Health Commercial |
$351.19
|
| Rate for Payer: Humana Commercial |
$314.22
|
| Rate for Payer: Humana KY Medicaid |
$127.13
|
| Rate for Payer: Humana Medicare Advantage |
$66.27
|
| Rate for Payer: Kentucky WC Medicaid |
$128.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$272.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.31
|
| Rate for Payer: Ohio Health Group HMO |
$277.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.60
|
| Rate for Payer: PHCS Commercial |
$354.88
|
| Rate for Payer: United Healthcare All Payer |
$325.31
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Professional
|
Both
|
$369.67
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
63600024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.20 |
| Max. Negotiated Rate |
$369.67 |
| Rate for Payer: Aetna Commercial |
$77.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$369.67
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Cash Price |
$184.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.20
|
| Rate for Payer: Multiplan PHCS |
$221.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$258.77
|
| Rate for Payer: UHCCP Medicaid |
$129.38
|
|
|
XIENCE SIERRA 2.25*12
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*12
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*15
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*15
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*18
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*18
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*23
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*23
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*28
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
XIENCE SIERRA 2.25*28
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
