|
XIENCE SIERRA 4.00*38
|
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 4.00*38
|
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 4.00*8
|
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 4.00*8
|
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 SKYPOINT 4.50*12
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem Medicaid |
$1,590.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Humana KY Medicaid |
$1,590.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,606.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
XIENCE SKYPOINT 4.50*12
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
XIFAXAN 200MG TABLET
|
Facility
|
IP
|
$28.23
|
|
|
Service Code
|
NDC 65649030103
|
| Hospital Charge Code |
25001731
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$27.10 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.02
|
| Rate for Payer: Cash Price |
$14.12
|
| Rate for Payer: Cigna Commercial |
$23.43
|
| Rate for Payer: First Health Commercial |
$26.82
|
| Rate for Payer: Humana Commercial |
$24.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.84
|
| Rate for Payer: Ohio Health Group HMO |
$21.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.48
|
| Rate for Payer: PHCS Commercial |
$27.10
|
| Rate for Payer: United Healthcare All Payer |
$24.84
|
|
|
XIFAXAN 200MG TABLET
|
Facility
|
OP
|
$28.23
|
|
|
Service Code
|
NDC 65649030103
|
| Hospital Charge Code |
25001731
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$27.10 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Anthem Medicaid |
$9.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.02
|
| Rate for Payer: Cash Price |
$14.12
|
| Rate for Payer: Cigna Commercial |
$23.43
|
| Rate for Payer: First Health Commercial |
$26.82
|
| Rate for Payer: Humana Commercial |
$24.00
|
| Rate for Payer: Humana KY Medicaid |
$9.71
|
| Rate for Payer: Kentucky WC Medicaid |
$9.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.84
|
| Rate for Payer: Ohio Health Group HMO |
$21.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.48
|
| Rate for Payer: PHCS Commercial |
$27.10
|
| Rate for Payer: United Healthcare All Payer |
$24.84
|
|
|
XIFAXAN 550 MG TABLET
|
Facility
|
OP
|
$129.72
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
25001732
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.92 |
| Max. Negotiated Rate |
$124.53 |
| Rate for Payer: Aetna Commercial |
$99.88
|
| Rate for Payer: Anthem Medicaid |
$44.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$101.18
|
| Rate for Payer: Cash Price |
$64.86
|
| Rate for Payer: Cigna Commercial |
$107.67
|
| Rate for Payer: First Health Commercial |
$123.23
|
| Rate for Payer: Humana Commercial |
$110.26
|
| Rate for Payer: Humana KY Medicaid |
$44.61
|
| Rate for Payer: Kentucky WC Medicaid |
$45.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.15
|
| Rate for Payer: Ohio Health Group HMO |
$97.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.51
|
| Rate for Payer: PHCS Commercial |
$124.53
|
| Rate for Payer: United Healthcare All Payer |
$114.15
|
|
|
XIFAXAN 550 MG TABLET
|
Facility
|
IP
|
$129.72
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
25001732
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.92 |
| Max. Negotiated Rate |
$124.53 |
| Rate for Payer: Aetna Commercial |
$99.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$101.18
|
| Rate for Payer: Cash Price |
$64.86
|
| Rate for Payer: Cigna Commercial |
$107.67
|
| Rate for Payer: First Health Commercial |
$123.23
|
| Rate for Payer: Humana Commercial |
$110.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.15
|
| Rate for Payer: Ohio Health Group HMO |
$97.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.51
|
| Rate for Payer: PHCS Commercial |
$124.53
|
| Rate for Payer: United Healthcare All Payer |
$114.15
|
|
|
XMI ULTRA
|
Facility
|
IP
|
$9,113.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,734.12 |
| Max. Negotiated Rate |
$8,749.20 |
| Rate for Payer: Aetna Commercial |
$7,017.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,108.73
|
| Rate for Payer: Cash Price |
$4,556.88
|
| Rate for Payer: Cigna Commercial |
$7,564.41
|
| Rate for Payer: First Health Commercial |
$8,658.06
|
| Rate for Payer: Humana Commercial |
$7,746.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,473.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,725.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,734.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,020.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,835.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,291.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,928.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,288.49
|
| Rate for Payer: PHCS Commercial |
$8,749.20
|
| Rate for Payer: United Healthcare All Payer |
$8,020.10
|
|
|
XMI ULTRA
|
Facility
|
OP
|
$9,113.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,734.12 |
| Max. Negotiated Rate |
$8,749.20 |
| Rate for Payer: Aetna Commercial |
$7,017.59
|
| Rate for Payer: Anthem Medicaid |
$3,134.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,108.73
|
| Rate for Payer: Cash Price |
$4,556.88
|
| Rate for Payer: Cigna Commercial |
$7,564.41
|
| Rate for Payer: First Health Commercial |
$8,658.06
|
| Rate for Payer: Humana Commercial |
$7,746.69
|
| Rate for Payer: Humana KY Medicaid |
$3,134.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3,166.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,473.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,725.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,734.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,197.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,020.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,835.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,291.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,928.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,288.49
|
| Rate for Payer: PHCS Commercial |
$8,749.20
|
| Rate for Payer: United Healthcare All Payer |
$8,020.10
|
|
|
XOLAIR 150MG SYRINGE
|
Facility
|
OP
|
$7,717.85
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.56 |
| Max. Negotiated Rate |
$7,409.14 |
| Rate for Payer: Aetna Commercial |
$5,942.74
|
| Rate for Payer: Anthem Medicaid |
$2,654.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$40.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,019.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$56.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.76
|
| Rate for Payer: Cash Price |
$3,858.93
|
| Rate for Payer: Cash Price |
$3,858.93
|
| Rate for Payer: Cigna Commercial |
$6,405.82
|
| Rate for Payer: First Health Commercial |
$7,331.96
|
| Rate for Payer: Humana Commercial |
$6,560.17
|
| Rate for Payer: Humana KY Medicaid |
$2,654.17
|
| Rate for Payer: Humana Medicare Advantage |
$40.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,681.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,328.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,695.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,707.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,791.71
|
| Rate for Payer: Ohio Health Group HMO |
$5,788.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,174.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,714.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,325.32
|
| Rate for Payer: PHCS Commercial |
$7,409.14
|
| Rate for Payer: United Healthcare All Payer |
$6,791.71
|
|
|
XOLAIR 150MG SYRINGE
|
Facility
|
IP
|
$7,717.85
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,315.36 |
| Max. Negotiated Rate |
$7,409.14 |
| Rate for Payer: Aetna Commercial |
$5,942.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,019.92
|
| Rate for Payer: Cash Price |
$3,858.93
|
| Rate for Payer: Cigna Commercial |
$6,405.82
|
| Rate for Payer: First Health Commercial |
$7,331.96
|
| Rate for Payer: Humana Commercial |
$6,560.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,328.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,695.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,315.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,791.71
|
| Rate for Payer: Ohio Health Group HMO |
$5,788.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,174.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,714.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,325.32
|
| Rate for Payer: PHCS Commercial |
$7,409.14
|
| Rate for Payer: United Healthcare All Payer |
$6,791.71
|
|
|
XOLAIR 150MG VIAL
|
Facility
|
OP
|
$7,717.85
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.56 |
| Max. Negotiated Rate |
$7,409.14 |
| Rate for Payer: Aetna Commercial |
$5,942.74
|
| Rate for Payer: Anthem Medicaid |
$2,654.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$40.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,019.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$56.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.76
|
| Rate for Payer: Cash Price |
$3,858.93
|
| Rate for Payer: Cash Price |
$3,858.93
|
| Rate for Payer: Cigna Commercial |
$6,405.82
|
| Rate for Payer: First Health Commercial |
$7,331.96
|
| Rate for Payer: Humana Commercial |
$6,560.17
|
| Rate for Payer: Humana KY Medicaid |
$2,654.17
|
| Rate for Payer: Humana Medicare Advantage |
$40.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,681.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,328.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,695.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,707.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,791.71
|
| Rate for Payer: Ohio Health Group HMO |
$5,788.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,174.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,714.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,325.32
|
| Rate for Payer: PHCS Commercial |
$7,409.14
|
| Rate for Payer: United Healthcare All Payer |
$6,791.71
|
|
|
XOLAIR 150MG VIAL
|
Facility
|
IP
|
$7,717.85
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,315.36 |
| Max. Negotiated Rate |
$7,409.14 |
| Rate for Payer: Aetna Commercial |
$5,942.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,019.92
|
| Rate for Payer: Cash Price |
$3,858.93
|
| Rate for Payer: Cigna Commercial |
$6,405.82
|
| Rate for Payer: First Health Commercial |
$7,331.96
|
| Rate for Payer: Humana Commercial |
$6,560.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,328.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,695.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,315.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,791.71
|
| Rate for Payer: Ohio Health Group HMO |
$5,788.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,174.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,714.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,325.32
|
| Rate for Payer: PHCS Commercial |
$7,409.14
|
| Rate for Payer: United Healthcare All Payer |
$6,791.71
|
|
|
XOLAIR 75MG/0.5ML SYRINGE
|
Facility
|
OP
|
$3,858.93
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.56 |
| Max. Negotiated Rate |
$3,704.57 |
| Rate for Payer: Aetna Commercial |
$2,971.38
|
| Rate for Payer: Anthem Medicaid |
$1,327.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$40.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,009.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$56.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.76
|
| Rate for Payer: Cash Price |
$1,929.46
|
| Rate for Payer: Cash Price |
$1,929.46
|
| Rate for Payer: Cigna Commercial |
$3,202.91
|
| Rate for Payer: First Health Commercial |
$3,665.98
|
| Rate for Payer: Humana Commercial |
$3,280.09
|
| Rate for Payer: Humana KY Medicaid |
$1,327.09
|
| Rate for Payer: Humana Medicare Advantage |
$40.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,340.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,353.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.86
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,087.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,357.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,662.66
|
| Rate for Payer: PHCS Commercial |
$3,704.57
|
| Rate for Payer: United Healthcare All Payer |
$3,395.86
|
|
|
XOLAIR 75MG/0.5ML SYRINGE
|
Facility
|
IP
|
$3,858.93
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
25002272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,157.68 |
| Max. Negotiated Rate |
$3,704.57 |
| Rate for Payer: Aetna Commercial |
$2,971.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,009.97
|
| Rate for Payer: Cash Price |
$1,929.46
|
| Rate for Payer: Cigna Commercial |
$3,202.91
|
| Rate for Payer: First Health Commercial |
$3,665.98
|
| Rate for Payer: Humana Commercial |
$3,280.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.86
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,087.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,357.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,662.66
|
| Rate for Payer: PHCS Commercial |
$3,704.57
|
| Rate for Payer: United Healthcare All Payer |
$3,395.86
|
|
|
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 |
$6.71 |
| 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 |
$17.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.43
|
| Rate for Payer: PHCS Commercial |
$21.47
|
| Rate for Payer: United Healthcare All Payer |
$19.68
|
|
|
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 |
$6.71 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: Aetna Commercial |
$17.22
|
| 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 |
$17.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.43
|
| 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 |
$3.24 |
| 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 |
$8.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.45
|
| 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 |
$3.24 |
| 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 |
$8.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.45
|
| Rate for Payer: PHCS Commercial |
$10.36
|
| Rate for Payer: United Healthcare All Payer |
$9.50
|
|
|
XOPENEX HFA INHALER 15 GM
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 591292754
|
| Hospital Charge Code |
25001734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| 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 |
$1.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.01
|
| Rate for Payer: PHCS Commercial |
$1.41
|
| Rate for Payer: United Healthcare All Payer |
$1.29
|
|
|
XOPENEX HFA INHALER 15 GM
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 591292754
|
| Hospital Charge Code |
25001734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.44 |
| 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 |
$1.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.01
|
| 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 |
$202.50 |
| 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 |
$540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$587.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.75
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
