|
XIENCE SIERRA 4.00*8
|
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 4.00*8
|
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 SKYPOINT 4.50*12
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
XIENCE SKYPOINT 4.50*12
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
XIFAXAN 200MG TABLET
|
Facility
|
IP
|
$27.59
|
|
|
Service Code
|
NDC 65649030103
|
| Hospital Charge Code |
25001731
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$26.49 |
| Rate for Payer: Aetna Commercial |
$21.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.52
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$22.90
|
| Rate for Payer: First Health Commercial |
$26.21
|
| Rate for Payer: Humana Commercial |
$23.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.28
|
| Rate for Payer: Ohio Health Group HMO |
$20.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.55
|
| Rate for Payer: PHCS Commercial |
$26.49
|
| Rate for Payer: United Healthcare All Payer |
$24.28
|
|
|
XIFAXAN 200MG TABLET
|
Facility
|
OP
|
$27.59
|
|
|
Service Code
|
NDC 65649030103
|
| Hospital Charge Code |
25001731
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$26.49 |
| Rate for Payer: Aetna Commercial |
$21.24
|
| Rate for Payer: Anthem Medicaid |
$9.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.52
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$22.90
|
| Rate for Payer: First Health Commercial |
$26.21
|
| Rate for Payer: Humana Commercial |
$23.45
|
| Rate for Payer: Humana KY Medicaid |
$9.49
|
| Rate for Payer: Kentucky WC Medicaid |
$9.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.28
|
| Rate for Payer: Ohio Health Group HMO |
$20.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.55
|
| Rate for Payer: PHCS Commercial |
$26.49
|
| Rate for Payer: United Healthcare All Payer |
$24.28
|
|
|
XIFAXAN 550 MG TABLET
|
Facility
|
IP
|
$126.45
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
25001732
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$121.39 |
| Rate for Payer: Humana Commercial |
$107.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.28
|
| Rate for Payer: Ohio Health Group HMO |
$94.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.20
|
| Rate for Payer: PHCS Commercial |
$121.39
|
| Rate for Payer: United Healthcare All Payer |
$111.28
|
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.63
|
| Rate for Payer: Cash Price |
$63.23
|
| Rate for Payer: Cigna Commercial |
$104.95
|
| Rate for Payer: First Health Commercial |
$120.13
|
|
|
XIFAXAN 550 MG TABLET
|
Facility
|
OP
|
$126.45
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
25001732
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$121.39 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Anthem Medicaid |
$43.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.63
|
| Rate for Payer: Cash Price |
$63.23
|
| Rate for Payer: Cigna Commercial |
$104.95
|
| Rate for Payer: First Health Commercial |
$120.13
|
| Rate for Payer: Humana Commercial |
$107.48
|
| Rate for Payer: Humana KY Medicaid |
$43.49
|
| Rate for Payer: Kentucky WC Medicaid |
$43.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.28
|
| Rate for Payer: Ohio Health Group HMO |
$94.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.20
|
| Rate for Payer: PHCS Commercial |
$121.39
|
| Rate for Payer: United Healthcare All Payer |
$111.28
|
|
|
XMI ULTRA
|
Facility
|
OP
|
$8,913.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,158.79 |
| Max. Negotiated Rate |
$8,557.20 |
| Rate for Payer: Aetna Commercial |
$6,863.59
|
| Rate for Payer: Anthem Medicaid |
$3,065.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,952.72
|
| Rate for Payer: Cash Price |
$4,456.88
|
| Rate for Payer: Cigna Commercial |
$7,398.41
|
| Rate for Payer: First Health Commercial |
$8,468.06
|
| Rate for Payer: Humana Commercial |
$7,576.69
|
| Rate for Payer: Humana KY Medicaid |
$3,065.44
|
| Rate for Payer: Kentucky WC Medicaid |
$3,096.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,309.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,578.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,674.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,126.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,844.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,685.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,782.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,158.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,763.26
|
| Rate for Payer: PHCS Commercial |
$8,557.20
|
| Rate for Payer: United Healthcare All Payer |
$7,844.10
|
|
|
XMI ULTRA
|
Facility
|
IP
|
$8,913.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,158.79 |
| Max. Negotiated Rate |
$8,557.20 |
| Rate for Payer: Aetna Commercial |
$6,863.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,952.72
|
| Rate for Payer: Cash Price |
$4,456.88
|
| Rate for Payer: Cigna Commercial |
$7,398.41
|
| Rate for Payer: First Health Commercial |
$8,468.06
|
| Rate for Payer: Humana Commercial |
$7,576.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,309.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,578.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,674.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,844.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,685.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,782.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,158.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,763.26
|
| Rate for Payer: PHCS Commercial |
$8,557.20
|
| Rate for Payer: United Healthcare All Payer |
$7,844.10
|
|
|
XOLAIR 150MG SYRINGE
|
Facility
|
IP
|
$7,548.03
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$981.24 |
| Max. Negotiated Rate |
$7,246.11 |
| Rate for Payer: Aetna Commercial |
$5,811.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,887.46
|
| Rate for Payer: Cash Price |
$3,774.01
|
| Rate for Payer: Cigna Commercial |
$6,264.86
|
| Rate for Payer: First Health Commercial |
$7,170.63
|
| Rate for Payer: Humana Commercial |
$6,415.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,189.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,570.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,264.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,642.27
|
| Rate for Payer: Ohio Health Group HMO |
$5,661.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$981.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,339.89
|
| Rate for Payer: PHCS Commercial |
$7,246.11
|
| Rate for Payer: United Healthcare All Payer |
$6,642.27
|
|
|
XOLAIR 150MG SYRINGE
|
Facility
|
OP
|
$7,548.03
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$7,246.11 |
| Rate for Payer: Aetna Commercial |
$5,811.98
|
| Rate for Payer: Anthem Medicaid |
$2,595.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$39.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,887.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$55.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$53.27
|
| Rate for Payer: Cash Price |
$3,774.01
|
| Rate for Payer: Cash Price |
$3,774.01
|
| Rate for Payer: Cigna Commercial |
$6,264.86
|
| Rate for Payer: First Health Commercial |
$7,170.63
|
| Rate for Payer: Humana Commercial |
$6,415.83
|
| Rate for Payer: Humana KY Medicaid |
$2,595.77
|
| Rate for Payer: Humana Medicare Advantage |
$39.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,622.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,189.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,570.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,647.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,642.27
|
| Rate for Payer: Ohio Health Group HMO |
$5,661.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$981.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,339.89
|
| Rate for Payer: PHCS Commercial |
$7,246.11
|
| Rate for Payer: United Healthcare All Payer |
$6,642.27
|
|
|
XOLAIR 150MG VIAL
|
Facility
|
IP
|
$7,548.03
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$981.24 |
| Max. Negotiated Rate |
$7,246.11 |
| Rate for Payer: Aetna Commercial |
$5,811.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,887.46
|
| Rate for Payer: Cash Price |
$3,774.01
|
| Rate for Payer: Cigna Commercial |
$6,264.86
|
| Rate for Payer: First Health Commercial |
$7,170.63
|
| Rate for Payer: Humana Commercial |
$6,415.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,189.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,570.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,264.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,642.27
|
| Rate for Payer: Ohio Health Group HMO |
$5,661.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$981.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,339.89
|
| Rate for Payer: PHCS Commercial |
$7,246.11
|
| Rate for Payer: United Healthcare All Payer |
$6,642.27
|
|
|
XOLAIR 150MG VIAL
|
Facility
|
OP
|
$7,548.03
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$7,246.11 |
| Rate for Payer: Aetna Commercial |
$5,811.98
|
| Rate for Payer: Anthem Medicaid |
$2,595.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$39.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,887.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$55.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$53.27
|
| Rate for Payer: Cash Price |
$3,774.01
|
| Rate for Payer: Cash Price |
$3,774.01
|
| Rate for Payer: Cigna Commercial |
$6,264.86
|
| Rate for Payer: First Health Commercial |
$7,170.63
|
| Rate for Payer: Humana Commercial |
$6,415.83
|
| Rate for Payer: Humana KY Medicaid |
$2,595.77
|
| Rate for Payer: Humana Medicare Advantage |
$39.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,622.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,189.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,570.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,647.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,642.27
|
| Rate for Payer: Ohio Health Group HMO |
$5,661.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$981.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,339.89
|
| Rate for Payer: PHCS Commercial |
$7,246.11
|
| Rate for Payer: United Healthcare All Payer |
$6,642.27
|
|
|
XOLAIR 75MG/0.5ML SYRINGE
|
Facility
|
OP
|
$3,774.02
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$3,623.06 |
| Rate for Payer: Aetna Commercial |
$2,906.00
|
| Rate for Payer: Anthem Medicaid |
$1,297.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$39.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,943.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$55.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$53.27
|
| Rate for Payer: Cash Price |
$1,887.01
|
| Rate for Payer: Cash Price |
$1,887.01
|
| Rate for Payer: Cigna Commercial |
$3,132.44
|
| Rate for Payer: First Health Commercial |
$3,585.32
|
| Rate for Payer: Humana Commercial |
$3,207.92
|
| Rate for Payer: Humana KY Medicaid |
$1,297.89
|
| Rate for Payer: Humana Medicare Advantage |
$39.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,323.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,321.14
|
| Rate for Payer: Ohio Health Group HMO |
$2,830.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$754.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,169.95
|
| Rate for Payer: PHCS Commercial |
$3,623.06
|
| Rate for Payer: United Healthcare All Payer |
$3,321.14
|
|
|
XOLAIR 75MG/0.5ML SYRINGE
|
Facility
|
IP
|
$3,774.02
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$490.62 |
| Max. Negotiated Rate |
$3,623.06 |
| Rate for Payer: Aetna Commercial |
$2,906.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,943.74
|
| Rate for Payer: Cash Price |
$1,887.01
|
| Rate for Payer: Cigna Commercial |
$3,132.44
|
| Rate for Payer: First Health Commercial |
$3,585.32
|
| Rate for Payer: Humana Commercial |
$3,207.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,321.14
|
| Rate for Payer: Ohio Health Group HMO |
$2,830.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$754.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,169.95
|
| Rate for Payer: PHCS Commercial |
$3,623.06
|
| Rate for Payer: United Healthcare All Payer |
$3,321.14
|
|
|
XOPENEX 1.25MG/0.5ML EQU VLNEB
|
Facility
|
IP
|
$22.36
|
|
|
Service Code
|
NDC 378699331
|
| Hospital Charge Code |
25003604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.44
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cigna Commercial |
$18.56
|
| Rate for Payer: First Health Commercial |
$21.24
|
| Rate for Payer: Humana Commercial |
$19.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.68
|
| Rate for Payer: Ohio Health Group HMO |
$16.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$21.47
|
| Rate for Payer: United Healthcare All Payer |
$19.68
|
| Rate for Payer: Aetna Commercial |
$17.22
|
|
|
XOPENEX 1.25MG/0.5ML EQU VLNEB
|
Facility
|
OP
|
$22.36
|
|
|
Service Code
|
NDC 378699331
|
| Hospital Charge Code |
25003604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: Aetna Commercial |
$17.22
|
| Rate for Payer: Anthem Medicaid |
$7.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.44
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cigna Commercial |
$18.56
|
| Rate for Payer: First Health Commercial |
$21.24
|
| Rate for Payer: Humana Commercial |
$19.01
|
| Rate for Payer: Humana KY Medicaid |
$7.69
|
| Rate for Payer: Kentucky WC Medicaid |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.68
|
| Rate for Payer: Ohio Health Group HMO |
$16.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$21.47
|
| Rate for Payer: United Healthcare All Payer |
$19.68
|
|
|
XOPENEX 1.25MG/3ML NEB (DAW)
|
Facility
|
OP
|
$10.79
|
|
|
Service Code
|
NDC 76204090011
|
| Hospital Charge Code |
25003605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.36 |
| Rate for Payer: Aetna Commercial |
$8.31
|
| Rate for Payer: Anthem Medicaid |
$3.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.42
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna Commercial |
$8.96
|
| Rate for Payer: First Health Commercial |
$10.25
|
| Rate for Payer: Humana Commercial |
$9.17
|
| Rate for Payer: Humana KY Medicaid |
$3.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.50
|
| Rate for Payer: Ohio Health Group HMO |
$8.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$10.36
|
| Rate for Payer: United Healthcare All Payer |
$9.50
|
|
|
XOPENEX 1.25MG/3ML NEB (DAW)
|
Facility
|
IP
|
$10.79
|
|
|
Service Code
|
NDC 76204090011
|
| Hospital Charge Code |
25003605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.36 |
| Rate for Payer: Aetna Commercial |
$8.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.42
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna Commercial |
$8.96
|
| Rate for Payer: First Health Commercial |
$10.25
|
| Rate for Payer: Humana Commercial |
$9.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.50
|
| Rate for Payer: Ohio Health Group HMO |
$8.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$10.36
|
| Rate for Payer: United Healthcare All Payer |
$9.50
|
|
|
XOPENEX HFA INHALER 15 GM
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 591292754
|
| Hospital Charge Code |
25001734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.15
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna Commercial |
$1.22
|
| Rate for Payer: First Health Commercial |
$1.40
|
| Rate for Payer: Humana Commercial |
$1.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.29
|
| Rate for Payer: Ohio Health Group HMO |
$1.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.46
|
| Rate for Payer: PHCS Commercial |
$1.41
|
| Rate for Payer: United Healthcare All Payer |
$1.29
|
|
|
XOPENEX HFA INHALER 15 GM
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 591292754
|
| Hospital Charge Code |
25001734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.13
|
| Rate for Payer: Anthem Medicaid |
$0.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.15
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna Commercial |
$1.22
|
| Rate for Payer: First Health Commercial |
$1.40
|
| Rate for Payer: Humana Commercial |
$1.25
|
| Rate for Payer: Humana KY Medicaid |
$0.51
|
| Rate for Payer: Kentucky WC Medicaid |
$0.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.29
|
| Rate for Payer: Ohio Health Group HMO |
$1.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.46
|
| Rate for Payer: PHCS Commercial |
$1.41
|
| Rate for Payer: United Healthcare All Payer |
$1.29
|
|
|
XPOSE FOR ENDOPROSTH - FEMORL
|
Facility
|
IP
|
$675.00
|
|
|
Service Code
|
HCPCS 34812
|
| Hospital Charge Code |
76101352
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.75 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$519.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$526.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$560.25
|
| Rate for Payer: First Health Commercial |
$641.25
|
| Rate for Payer: Humana Commercial |
$573.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$553.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.00
|
| Rate for Payer: Ohio Health Group HMO |
$506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.25
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
|
XPOSE FOR ENDOPROSTH - FEMORL
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
HCPCS 34812
|
| Hospital Charge Code |
76101352
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Aetna Commercial |
$621.39
|
| Rate for Payer: Anthem Medicaid |
$276.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$675.00
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$587.46
|
| Rate for Payer: Healthspan PPO |
$610.95
|
| Rate for Payer: Humana Medicaid |
$276.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$461.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$281.72
|
| Rate for Payer: Molina Healthcare Passport |
$276.20
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$472.50
|
| Rate for Payer: UHCCP Medicaid |
$236.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$278.96
|
|
|
XPOSE FOR ENDOPROSTH - FEMORL
|
Facility
|
OP
|
$675.00
|
|
|
Service Code
|
HCPCS 34812
|
| Hospital Charge Code |
76101352
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.75 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$519.75
|
| Rate for Payer: Anthem Medicaid |
$232.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$526.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$560.25
|
| Rate for Payer: First Health Commercial |
$641.25
|
| Rate for Payer: Humana Commercial |
$573.75
|
| Rate for Payer: Humana KY Medicaid |
$232.13
|
| Rate for Payer: Kentucky WC Medicaid |
$234.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$553.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$236.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.00
|
| Rate for Payer: Ohio Health Group HMO |
$506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.25
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
