|
X-FUSE TRIAL LARGE 15 DEG
|
Facility
|
IP
|
$1,797.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$539.34 |
| Max. Negotiated Rate |
$1,725.89 |
| Rate for Payer: Aetna Commercial |
$1,384.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,402.28
|
| Rate for Payer: Cash Price |
$898.90
|
| Rate for Payer: Cigna Commercial |
$1,492.17
|
| Rate for Payer: First Health Commercial |
$1,707.91
|
| Rate for Payer: Humana Commercial |
$1,528.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,474.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,326.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$539.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,582.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,348.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,438.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,564.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.48
|
| Rate for Payer: PHCS Commercial |
$1,725.89
|
| Rate for Payer: United Healthcare All Payer |
$1,582.06
|
|
|
X-FUSE TRIAL LARGE 15 DEG
|
Facility
|
OP
|
$1,797.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$539.34 |
| Max. Negotiated Rate |
$1,725.89 |
| Rate for Payer: Aetna Commercial |
$1,384.31
|
| Rate for Payer: Anthem Medicaid |
$618.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,402.28
|
| Rate for Payer: Cash Price |
$898.90
|
| Rate for Payer: Cigna Commercial |
$1,492.17
|
| Rate for Payer: First Health Commercial |
$1,707.91
|
| Rate for Payer: Humana Commercial |
$1,528.13
|
| Rate for Payer: Humana KY Medicaid |
$618.26
|
| Rate for Payer: Kentucky WC Medicaid |
$624.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,474.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,326.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$539.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$630.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,582.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,348.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,438.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,564.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.48
|
| Rate for Payer: PHCS Commercial |
$1,725.89
|
| Rate for Payer: United Healthcare All Payer |
$1,582.06
|
|
|
X-FUSE TRIAL LARGE 25 DEG
|
Facility
|
IP
|
$1,797.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$539.34 |
| Max. Negotiated Rate |
$1,725.89 |
| Rate for Payer: Aetna Commercial |
$1,384.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,402.28
|
| Rate for Payer: Cash Price |
$898.90
|
| Rate for Payer: Cigna Commercial |
$1,492.17
|
| Rate for Payer: First Health Commercial |
$1,707.91
|
| Rate for Payer: Humana Commercial |
$1,528.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,474.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,326.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$539.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,582.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,348.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,438.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,564.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.48
|
| Rate for Payer: PHCS Commercial |
$1,725.89
|
| Rate for Payer: United Healthcare All Payer |
$1,582.06
|
|
|
X-FUSE TRIAL LARGE 25 DEG
|
Facility
|
OP
|
$1,797.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$539.34 |
| Max. Negotiated Rate |
$1,725.89 |
| Rate for Payer: Aetna Commercial |
$1,384.31
|
| Rate for Payer: Anthem Medicaid |
$618.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,402.28
|
| Rate for Payer: Cash Price |
$898.90
|
| Rate for Payer: Cigna Commercial |
$1,492.17
|
| Rate for Payer: First Health Commercial |
$1,707.91
|
| Rate for Payer: Humana Commercial |
$1,528.13
|
| Rate for Payer: Humana KY Medicaid |
$618.26
|
| Rate for Payer: Kentucky WC Medicaid |
$624.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,474.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,326.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$539.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$630.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,582.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,348.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,438.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,564.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.48
|
| Rate for Payer: PHCS Commercial |
$1,725.89
|
| Rate for Payer: United Healthcare All Payer |
$1,582.06
|
|
|
X-FUSE TRIAL XLARGE 0 DEG
|
Facility
|
OP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem Medicaid |
$619.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Humana KY Medicaid |
$619.57
|
| Rate for Payer: Kentucky WC Medicaid |
$625.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$632.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
X-FUSE TRIAL XLARGE 0 DEG
|
Facility
|
IP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
X-FUSE TRIAL XLARGE 15 DEG
|
Facility
|
IP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
X-FUSE TRIAL XLARGE 15 DEG
|
Facility
|
OP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem Medicaid |
$619.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Humana KY Medicaid |
$619.57
|
| Rate for Payer: Kentucky WC Medicaid |
$625.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$632.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
XGEVA 1MG [120MG/1.7ML VIAL]
|
Facility
|
OP
|
$18,801.08
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
25002004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.24 |
| Max. Negotiated Rate |
$18,049.04 |
| Rate for Payer: Aetna Commercial |
$14,476.83
|
| Rate for Payer: Anthem Medicaid |
$6,465.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$29.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,664.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$40.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$39.47
|
| Rate for Payer: Cash Price |
$9,400.54
|
| Rate for Payer: Cash Price |
$9,400.54
|
| Rate for Payer: Cigna Commercial |
$15,604.90
|
| Rate for Payer: First Health Commercial |
$17,861.03
|
| Rate for Payer: Humana Commercial |
$15,980.92
|
| Rate for Payer: Humana KY Medicaid |
$6,465.69
|
| Rate for Payer: Humana Medicare Advantage |
$29.24
|
| Rate for Payer: Kentucky WC Medicaid |
$6,531.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,416.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,875.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,595.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,544.95
|
| Rate for Payer: Ohio Health Group HMO |
$14,100.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,040.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,356.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,972.75
|
| Rate for Payer: PHCS Commercial |
$18,049.04
|
| Rate for Payer: United Healthcare All Payer |
$16,544.95
|
|
|
XGEVA 1MG [120MG/1.7ML VIAL]
|
Facility
|
IP
|
$18,801.08
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
25002004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,640.32 |
| Max. Negotiated Rate |
$18,049.04 |
| Rate for Payer: Aetna Commercial |
$14,476.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,664.84
|
| Rate for Payer: Cash Price |
$9,400.54
|
| Rate for Payer: Cigna Commercial |
$15,604.90
|
| Rate for Payer: First Health Commercial |
$17,861.03
|
| Rate for Payer: Humana Commercial |
$15,980.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,416.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,875.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,640.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,544.95
|
| Rate for Payer: Ohio Health Group HMO |
$14,100.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,040.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,356.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,972.75
|
| Rate for Payer: PHCS Commercial |
$18,049.04
|
| Rate for Payer: United Healthcare All Payer |
$16,544.95
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
IP
|
$38,738.71
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
25001968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,621.61 |
| Max. Negotiated Rate |
$37,189.16 |
| Rate for Payer: Aetna Commercial |
$29,828.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,216.19
|
| Rate for Payer: Cash Price |
$19,369.36
|
| Rate for Payer: Cigna Commercial |
$32,153.13
|
| Rate for Payer: First Health Commercial |
$36,801.77
|
| Rate for Payer: Humana Commercial |
$32,927.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,765.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,589.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,621.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,090.06
|
| Rate for Payer: Ohio Health Group HMO |
$29,054.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30,990.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33,702.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26,729.71
|
| Rate for Payer: PHCS Commercial |
$37,189.16
|
| Rate for Payer: United Healthcare All Payer |
$34,090.06
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
OP
|
$38,738.71
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
25001968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.16 |
| Max. Negotiated Rate |
$37,189.16 |
| Rate for Payer: Aetna Commercial |
$29,828.81
|
| Rate for Payer: Anthem Medicaid |
$13,322.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$73.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,216.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$102.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.77
|
| Rate for Payer: Cash Price |
$19,369.36
|
| Rate for Payer: Cash Price |
$19,369.36
|
| Rate for Payer: Cigna Commercial |
$32,153.13
|
| Rate for Payer: First Health Commercial |
$36,801.77
|
| Rate for Payer: Humana Commercial |
$32,927.90
|
| Rate for Payer: Humana KY Medicaid |
$13,322.24
|
| Rate for Payer: Humana Medicare Advantage |
$73.16
|
| Rate for Payer: Kentucky WC Medicaid |
$13,457.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,765.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,589.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,589.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,090.06
|
| Rate for Payer: Ohio Health Group HMO |
$29,054.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30,990.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33,702.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26,729.71
|
| Rate for Payer: PHCS Commercial |
$37,189.16
|
| Rate for Payer: United Healthcare All Payer |
$34,090.06
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
IP
|
$430.43
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
63600024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.13 |
| Max. Negotiated Rate |
$413.21 |
| Rate for Payer: Aetna Commercial |
$331.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.74
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cigna Commercial |
$357.26
|
| Rate for Payer: First Health Commercial |
$408.91
|
| Rate for Payer: Humana Commercial |
$365.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.78
|
| Rate for Payer: Ohio Health Group HMO |
$322.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.00
|
| Rate for Payer: PHCS Commercial |
$413.21
|
| Rate for Payer: United Healthcare All Payer |
$378.78
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Professional
|
Both
|
$430.43
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
63600024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.16 |
| Max. Negotiated Rate |
$258.26 |
| Rate for Payer: Aetna Commercial |
$77.50
|
| Rate for Payer: Ambetter Exchange |
$73.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$73.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$73.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.79
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$73.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.16
|
| Rate for Payer: Multiplan PHCS |
$258.26
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$95.11
|
| Rate for Payer: UHCCP Medicaid |
$150.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$73.16
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
OP
|
$430.43
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
636T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.16 |
| Max. Negotiated Rate |
$413.21 |
| Rate for Payer: Aetna Commercial |
$331.43
|
| Rate for Payer: Anthem Medicaid |
$148.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$73.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$102.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.77
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cigna Commercial |
$357.26
|
| Rate for Payer: First Health Commercial |
$408.91
|
| Rate for Payer: Humana Commercial |
$365.87
|
| Rate for Payer: Humana KY Medicaid |
$148.02
|
| Rate for Payer: Humana Medicare Advantage |
$73.16
|
| Rate for Payer: Kentucky WC Medicaid |
$149.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.78
|
| Rate for Payer: Ohio Health Group HMO |
$322.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.00
|
| Rate for Payer: PHCS Commercial |
$413.21
|
| Rate for Payer: United Healthcare All Payer |
$378.78
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
OP
|
$430.43
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
63600024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.16 |
| Max. Negotiated Rate |
$413.21 |
| Rate for Payer: Aetna Commercial |
$331.43
|
| Rate for Payer: Anthem Medicaid |
$148.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$73.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$102.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.77
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cigna Commercial |
$357.26
|
| Rate for Payer: First Health Commercial |
$408.91
|
| Rate for Payer: Humana Commercial |
$365.87
|
| Rate for Payer: Humana KY Medicaid |
$148.02
|
| Rate for Payer: Humana Medicare Advantage |
$73.16
|
| Rate for Payer: Kentucky WC Medicaid |
$149.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.78
|
| Rate for Payer: Ohio Health Group HMO |
$322.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.00
|
| Rate for Payer: PHCS Commercial |
$413.21
|
| Rate for Payer: United Healthcare All Payer |
$378.78
|
|
|
XIAFLEX 0.01MG [0.9 MG VIAL]
|
Facility
|
IP
|
$430.43
|
|
|
Service Code
|
HCPCS J0775
|
| Hospital Charge Code |
636T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.13 |
| Max. Negotiated Rate |
$413.21 |
| Rate for Payer: Aetna Commercial |
$331.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.74
|
| Rate for Payer: Cash Price |
$215.22
|
| Rate for Payer: Cigna Commercial |
$357.26
|
| Rate for Payer: First Health Commercial |
$408.91
|
| Rate for Payer: Humana Commercial |
$365.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.78
|
| Rate for Payer: Ohio Health Group HMO |
$322.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.00
|
| Rate for Payer: PHCS Commercial |
$413.21
|
| Rate for Payer: United Healthcare All Payer |
$378.78
|
|
|
XIENCE SIERRA 2.25*12
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*12
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*15
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*15
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*18
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*18
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*23
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*23
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
