|
WRINKLE/TEXTURE REPAIR 1.7 OZ
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
22200164
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$139.20 |
| Rate for Payer: Aetna Commercial |
$111.65
|
| Rate for Payer: Anthem Medicaid |
$49.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.10
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$120.35
|
| Rate for Payer: First Health Commercial |
$137.75
|
| Rate for Payer: Humana Commercial |
$123.25
|
| Rate for Payer: Humana KY Medicaid |
$49.87
|
| Rate for Payer: Kentucky WC Medicaid |
$50.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.60
|
| Rate for Payer: Ohio Health Group HMO |
$108.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.05
|
| Rate for Payer: PHCS Commercial |
$139.20
|
| Rate for Payer: United Healthcare All Payer |
$127.60
|
|
|
WRINKLE/TEXTURE REPAIR 1.7 OZ
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
22200164
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$139.20 |
| Rate for Payer: Aetna Commercial |
$111.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.10
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$120.35
|
| Rate for Payer: First Health Commercial |
$137.75
|
| Rate for Payer: Humana Commercial |
$123.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.60
|
| Rate for Payer: Ohio Health Group HMO |
$108.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.05
|
| Rate for Payer: PHCS Commercial |
$139.20
|
| Rate for Payer: United Healthcare All Payer |
$127.60
|
|
|
WRINKLE + TEXTURE REPAIR 1 OZ
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
22200163
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.20
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
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 |
$63.00 |
| 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
|
|
|
WRINKLE + TEXTURE REPAIR 1 OZ
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
22200163
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem Medicaid |
$30.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.20
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Humana KY Medicaid |
$30.95
|
| Rate for Payer: Kentucky WC Medicaid |
$31.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
WRIST 3V
|
Professional
|
Both
|
$468.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
32000085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$280.80 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: Ambetter Exchange |
$37.11
|
| Rate for Payer: Anthem Medicaid |
$21.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.53
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cash Price |
$234.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$37.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.23
|
| Rate for Payer: Molina Healthcare Passport |
$21.79
|
| Rate for Payer: Multiplan PHCS |
$280.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$48.24
|
| Rate for Payer: UHCCP Medicaid |
$163.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.11
|
|
|
WRIST 3V
|
Facility
|
OP
|
$468.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
32000085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$449.28 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Anthem Medicaid |
$160.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$388.44
|
| Rate for Payer: First Health Commercial |
$444.60
|
| Rate for Payer: Humana Commercial |
$397.80
|
| Rate for Payer: Humana KY Medicaid |
$160.95
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$162.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$383.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$345.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$164.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$411.84
|
| Rate for Payer: Ohio Health Group HMO |
$351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$407.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$322.92
|
| Rate for Payer: PHCS Commercial |
$449.28
|
| Rate for Payer: United Healthcare All Payer |
$411.84
|
|
|
WRIST 3V
|
Facility
|
IP
|
$468.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
32000085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$140.40 |
| Max. Negotiated Rate |
$449.28 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.04
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$388.44
|
| Rate for Payer: First Health Commercial |
$444.60
|
| Rate for Payer: Humana Commercial |
$397.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$383.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$345.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$411.84
|
| Rate for Payer: Ohio Health Group HMO |
$351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$407.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$322.92
|
| Rate for Payer: PHCS Commercial |
$449.28
|
| Rate for Payer: United Healthcare All Payer |
$411.84
|
|
|
WRIST 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: Ambetter Exchange |
$37.11
|
| Rate for Payer: Anthem Medicaid |
$21.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.53
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$37.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.11
|
| 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 |
$48.24
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.11
|
|
|
WRIST 3V(T
|
Facility
|
IP
|
$428.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
320T0085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.40 |
| Max. Negotiated Rate |
$410.88 |
| Rate for Payer: Aetna Commercial |
$329.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$333.84
|
| Rate for Payer: Cash Price |
$214.00
|
| Rate for Payer: Cigna Commercial |
$355.24
|
| Rate for Payer: First Health Commercial |
$406.60
|
| Rate for Payer: Humana Commercial |
$363.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$350.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$315.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$128.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$376.64
|
| Rate for Payer: Ohio Health Group HMO |
$321.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$342.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$372.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$295.32
|
| Rate for Payer: PHCS Commercial |
$410.88
|
| Rate for Payer: United Healthcare All Payer |
$376.64
|
|
|
WRIST 3V(T
|
Facility
|
OP
|
$428.00
|
|
|
Service Code
|
HCPCS 73110
|
| Hospital Charge Code |
320T0085
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$410.88 |
| Rate for Payer: Aetna Commercial |
$329.56
|
| Rate for Payer: Anthem Medicaid |
$147.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$333.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$214.00
|
| Rate for Payer: Cash Price |
$214.00
|
| Rate for Payer: Cigna Commercial |
$355.24
|
| Rate for Payer: First Health Commercial |
$406.60
|
| Rate for Payer: Humana Commercial |
$363.80
|
| Rate for Payer: Humana KY Medicaid |
$147.19
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$148.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$350.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$315.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$376.64
|
| Rate for Payer: Ohio Health Group HMO |
$321.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$342.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$372.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$295.32
|
| Rate for Payer: PHCS Commercial |
$410.88
|
| Rate for Payer: United Healthcare All Payer |
$376.64
|
|
|
WRIST FUNSION PLATE REAMR HEAD
|
Facility
|
OP
|
$3,410.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,023.00 |
| Max. Negotiated Rate |
$3,273.60 |
| Rate for Payer: Aetna Commercial |
$2,625.70
|
| Rate for Payer: Anthem Medicaid |
$1,172.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,659.80
|
| Rate for Payer: Cash Price |
$1,705.00
|
| Rate for Payer: Cigna Commercial |
$2,830.30
|
| Rate for Payer: First Health Commercial |
$3,239.50
|
| Rate for Payer: Humana Commercial |
$2,898.50
|
| Rate for Payer: Humana KY Medicaid |
$1,172.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,184.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,796.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,516.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,023.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,196.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,000.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,557.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,966.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,352.90
|
| Rate for Payer: PHCS Commercial |
$3,273.60
|
| Rate for Payer: United Healthcare All Payer |
$3,000.80
|
|
|
WRIST FUNSION PLATE REAMR HEAD
|
Facility
|
IP
|
$3,410.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,023.00 |
| Max. Negotiated Rate |
$3,273.60 |
| Rate for Payer: Aetna Commercial |
$2,625.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,659.80
|
| Rate for Payer: Cash Price |
$1,705.00
|
| Rate for Payer: Cigna Commercial |
$2,830.30
|
| Rate for Payer: First Health Commercial |
$3,239.50
|
| Rate for Payer: Humana Commercial |
$2,898.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,796.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,516.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,023.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,000.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,557.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,966.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,352.90
|
| Rate for Payer: PHCS Commercial |
$3,273.60
|
| Rate for Payer: United Healthcare All Payer |
$3,000.80
|
|
|
XALATAN (LATANOPROST) ML/2.5ML
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
25001722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.32 |
| 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 |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.75
|
| Rate for Payer: PHCS Commercial |
$1.04
|
| Rate for Payer: United Healthcare All Payer |
$0.95
|
|
|
XALATAN (LATANOPROST) ML/2.5ML
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
25001722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.32 |
| 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 |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.75
|
| Rate for Payer: PHCS Commercial |
$1.04
|
| Rate for Payer: United Healthcare All Payer |
$0.95
|
|
|
XARELTO 10MG TABLET
|
Facility
|
IP
|
$36.94
|
|
|
Service Code
|
NDC 50458058010
|
| Hospital Charge Code |
25001727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.81
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna Commercial |
$30.66
|
| Rate for Payer: First Health Commercial |
$35.09
|
| Rate for Payer: Humana Commercial |
$31.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.51
|
| Rate for Payer: Ohio Health Group HMO |
$27.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.49
|
| Rate for Payer: PHCS Commercial |
$35.46
|
| Rate for Payer: United Healthcare All Payer |
$32.51
|
|
|
XARELTO 10MG TABLET
|
Facility
|
OP
|
$36.94
|
|
|
Service Code
|
NDC 50458058010
|
| Hospital Charge Code |
25001727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Anthem Medicaid |
$12.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.81
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna Commercial |
$30.66
|
| Rate for Payer: First Health Commercial |
$35.09
|
| Rate for Payer: Humana Commercial |
$31.40
|
| Rate for Payer: Humana KY Medicaid |
$12.70
|
| Rate for Payer: Kentucky WC Medicaid |
$12.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.51
|
| Rate for Payer: Ohio Health Group HMO |
$27.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.49
|
| Rate for Payer: PHCS Commercial |
$35.46
|
| Rate for Payer: United Healthcare All Payer |
$32.51
|
|
|
XARELTO 15 MG TABLET
|
Facility
|
IP
|
$36.94
|
|
|
Service Code
|
NDC 50458057810
|
| Hospital Charge Code |
25001728
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.81
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna Commercial |
$30.66
|
| Rate for Payer: First Health Commercial |
$35.09
|
| Rate for Payer: Humana Commercial |
$31.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.51
|
| Rate for Payer: Ohio Health Group HMO |
$27.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.49
|
| Rate for Payer: PHCS Commercial |
$35.46
|
| Rate for Payer: United Healthcare All Payer |
$32.51
|
|
|
XARELTO 15 MG TABLET
|
Facility
|
OP
|
$36.94
|
|
|
Service Code
|
NDC 50458057810
|
| Hospital Charge Code |
25001728
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Anthem Medicaid |
$12.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.81
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna Commercial |
$30.66
|
| Rate for Payer: First Health Commercial |
$35.09
|
| Rate for Payer: Humana Commercial |
$31.40
|
| Rate for Payer: Humana KY Medicaid |
$12.70
|
| Rate for Payer: Kentucky WC Medicaid |
$12.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.51
|
| Rate for Payer: Ohio Health Group HMO |
$27.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.49
|
| Rate for Payer: PHCS Commercial |
$35.46
|
| Rate for Payer: United Healthcare All Payer |
$32.51
|
|
|
XARELTO 20MG TABLET
|
Facility
|
IP
|
$36.94
|
|
|
Service Code
|
NDC 50458057910
|
| Hospital Charge Code |
25001729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.81
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna Commercial |
$30.66
|
| Rate for Payer: First Health Commercial |
$35.09
|
| Rate for Payer: Humana Commercial |
$31.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.51
|
| Rate for Payer: Ohio Health Group HMO |
$27.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.49
|
| Rate for Payer: PHCS Commercial |
$35.46
|
| Rate for Payer: United Healthcare All Payer |
$32.51
|
|
|
XARELTO 20MG TABLET
|
Facility
|
OP
|
$36.94
|
|
|
Service Code
|
NDC 50458057910
|
| Hospital Charge Code |
25001729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Anthem Medicaid |
$12.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.81
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna Commercial |
$30.66
|
| Rate for Payer: First Health Commercial |
$35.09
|
| Rate for Payer: Humana Commercial |
$31.40
|
| Rate for Payer: Humana KY Medicaid |
$12.70
|
| Rate for Payer: Kentucky WC Medicaid |
$12.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.51
|
| Rate for Payer: Ohio Health Group HMO |
$27.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.49
|
| Rate for Payer: PHCS Commercial |
$35.46
|
| Rate for Payer: United Healthcare All Payer |
$32.51
|
|
|
XARELTO 2.5 MG TABLET
|
Facility
|
OP
|
$26.97
|
|
|
Service Code
|
NDC 50458057760
|
| Hospital Charge Code |
25003871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.09 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: Aetna Commercial |
$20.77
|
| Rate for Payer: Anthem Medicaid |
$9.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.04
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cigna Commercial |
$22.39
|
| Rate for Payer: First Health Commercial |
$25.62
|
| Rate for Payer: Humana Commercial |
$22.92
|
| Rate for Payer: Humana KY Medicaid |
$9.27
|
| Rate for Payer: Kentucky WC Medicaid |
$9.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.73
|
| Rate for Payer: Ohio Health Group HMO |
$20.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.61
|
| Rate for Payer: PHCS Commercial |
$25.89
|
| Rate for Payer: United Healthcare All Payer |
$23.73
|
|
|
XARELTO 2.5 MG TABLET
|
Facility
|
IP
|
$26.97
|
|
|
Service Code
|
NDC 50458057760
|
| Hospital Charge Code |
25003871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.09 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: Aetna Commercial |
$20.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.04
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cigna Commercial |
$22.39
|
| Rate for Payer: First Health Commercial |
$25.62
|
| Rate for Payer: Humana Commercial |
$22.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.73
|
| Rate for Payer: Ohio Health Group HMO |
$20.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.61
|
| Rate for Payer: PHCS Commercial |
$25.89
|
| Rate for Payer: United Healthcare All Payer |
$23.73
|
|
|
XELODA (50MG)150MG TABLET
|
Facility
|
OP
|
$73.90
|
|
|
Service Code
|
HCPCS J8522
|
| Hospital Charge Code |
25002533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$70.94 |
| Rate for Payer: Aetna Commercial |
$56.90
|
| Rate for Payer: Anthem Medicaid |
$25.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$36.95
|
| 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 |
$62.81
|
| Rate for Payer: Humana KY Medicaid |
$25.41
|
| Rate for Payer: Humana Medicare Advantage |
$0.05
|
| 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 |
$0.06
|
| 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 |
$59.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.99
|
| Rate for Payer: PHCS Commercial |
$70.94
|
| Rate for Payer: United Healthcare All Payer |
$65.03
|
|
|
XELODA (50MG)150MG TABLET
|
Facility
|
IP
|
$73.90
|
|
|
Service Code
|
HCPCS J8522
|
| Hospital Charge Code |
25002533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.17 |
| 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 |
$62.81
|
| 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 |
$59.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.99
|
| Rate for Payer: PHCS Commercial |
$70.94
|
| Rate for Payer: United Healthcare All Payer |
$65.03
|
|
