|
ELEOS COLLAR 28MM 12*120
|
Facility
|
IP
|
$22,652.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.78 |
| Max. Negotiated Rate |
$21,746.06 |
| Rate for Payer: Aetna Commercial |
$17,442.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,668.68
|
| Rate for Payer: Cash Price |
$11,326.08
|
| Rate for Payer: Cigna Commercial |
$18,801.28
|
| Rate for Payer: First Health Commercial |
$21,519.54
|
| Rate for Payer: Humana Commercial |
$19,254.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,574.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,717.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,795.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,933.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,989.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,530.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,944.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,022.17
|
| Rate for Payer: PHCS Commercial |
$21,746.06
|
| Rate for Payer: United Healthcare All Payer |
$19,933.89
|
|
|
ELEOS DISTAL FEM RT 65MM
|
Facility
|
IP
|
$36,080.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,690.46 |
| Max. Negotiated Rate |
$34,637.28 |
| Rate for Payer: Aetna Commercial |
$27,781.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,142.79
|
| Rate for Payer: Cash Price |
$18,040.25
|
| Rate for Payer: Cigna Commercial |
$29,946.82
|
| Rate for Payer: First Health Commercial |
$34,276.48
|
| Rate for Payer: Humana Commercial |
$30,668.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,586.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,627.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,824.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,750.84
|
| Rate for Payer: Ohio Health Group HMO |
$27,060.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,216.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,690.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,184.96
|
| Rate for Payer: PHCS Commercial |
$34,637.28
|
| Rate for Payer: United Healthcare All Payer |
$31,750.84
|
|
|
ELEOS DISTAL FEM RT 65MM
|
Facility
|
OP
|
$36,080.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,690.46 |
| Max. Negotiated Rate |
$34,637.28 |
| Rate for Payer: Aetna Commercial |
$27,781.98
|
| Rate for Payer: Anthem Medicaid |
$12,408.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,142.79
|
| Rate for Payer: Cash Price |
$18,040.25
|
| Rate for Payer: Cigna Commercial |
$29,946.82
|
| Rate for Payer: First Health Commercial |
$34,276.48
|
| Rate for Payer: Humana Commercial |
$30,668.42
|
| Rate for Payer: Humana KY Medicaid |
$12,408.08
|
| Rate for Payer: Kentucky WC Medicaid |
$12,534.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,586.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,627.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,824.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,657.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,750.84
|
| Rate for Payer: Ohio Health Group HMO |
$27,060.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,216.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,690.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,184.96
|
| Rate for Payer: PHCS Commercial |
$34,637.28
|
| Rate for Payer: United Healthcare All Payer |
$31,750.84
|
|
|
ELEOS STEM SPLINED ST 15*100MM
|
Facility
|
OP
|
$9,140.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.21 |
| Max. Negotiated Rate |
$8,774.45 |
| Rate for Payer: Aetna Commercial |
$7,037.84
|
| Rate for Payer: Anthem Medicaid |
$3,143.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,129.24
|
| Rate for Payer: Cash Price |
$4,570.02
|
| Rate for Payer: Cigna Commercial |
$7,586.24
|
| Rate for Payer: First Health Commercial |
$8,683.05
|
| Rate for Payer: Humana Commercial |
$7,769.04
|
| Rate for Payer: Humana KY Medicaid |
$3,143.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3,175.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,494.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,745.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,742.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,206.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,043.24
|
| Rate for Payer: Ohio Health Group HMO |
$6,855.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,828.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,188.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,833.42
|
| Rate for Payer: PHCS Commercial |
$8,774.45
|
| Rate for Payer: United Healthcare All Payer |
$8,043.24
|
|
|
ELEOS STEM SPLINED ST 15*100MM
|
Facility
|
IP
|
$9,140.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.21 |
| Max. Negotiated Rate |
$8,774.45 |
| Rate for Payer: Aetna Commercial |
$7,037.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,129.24
|
| Rate for Payer: Cash Price |
$4,570.02
|
| Rate for Payer: Cigna Commercial |
$7,586.24
|
| Rate for Payer: First Health Commercial |
$8,683.05
|
| Rate for Payer: Humana Commercial |
$7,769.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,494.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,745.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,742.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,043.24
|
| Rate for Payer: Ohio Health Group HMO |
$6,855.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,828.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,188.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,833.42
|
| Rate for Payer: PHCS Commercial |
$8,774.45
|
| Rate for Payer: United Healthcare All Payer |
$8,043.24
|
|
|
ELEOS STEM SPLINED ST 16*100MM
|
Facility
|
OP
|
$9,140.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.21 |
| Max. Negotiated Rate |
$8,774.45 |
| Rate for Payer: Aetna Commercial |
$7,037.84
|
| Rate for Payer: Anthem Medicaid |
$3,143.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,129.24
|
| Rate for Payer: Cash Price |
$4,570.02
|
| Rate for Payer: Cigna Commercial |
$7,586.24
|
| Rate for Payer: First Health Commercial |
$8,683.05
|
| Rate for Payer: Humana Commercial |
$7,769.04
|
| Rate for Payer: Humana KY Medicaid |
$3,143.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3,175.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,494.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,745.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,742.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,206.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,043.24
|
| Rate for Payer: Ohio Health Group HMO |
$6,855.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,828.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,188.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,833.42
|
| Rate for Payer: PHCS Commercial |
$8,774.45
|
| Rate for Payer: United Healthcare All Payer |
$8,043.24
|
|
|
ELEOS STEM SPLINED ST 16*100MM
|
Facility
|
IP
|
$9,140.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.21 |
| Max. Negotiated Rate |
$8,774.45 |
| Rate for Payer: Aetna Commercial |
$7,037.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,129.24
|
| Rate for Payer: Cash Price |
$4,570.02
|
| Rate for Payer: Cigna Commercial |
$7,586.24
|
| Rate for Payer: First Health Commercial |
$8,683.05
|
| Rate for Payer: Humana Commercial |
$7,769.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,494.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,745.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,742.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,043.24
|
| Rate for Payer: Ohio Health Group HMO |
$6,855.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,828.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,188.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,833.42
|
| Rate for Payer: PHCS Commercial |
$8,774.45
|
| Rate for Payer: United Healthcare All Payer |
$8,043.24
|
|
|
ELEOS STEM SPLINED ST 18*100MM
|
Facility
|
IP
|
$9,140.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.21 |
| Max. Negotiated Rate |
$8,774.45 |
| Rate for Payer: Aetna Commercial |
$7,037.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,129.24
|
| Rate for Payer: Cash Price |
$4,570.02
|
| Rate for Payer: Cigna Commercial |
$7,586.24
|
| Rate for Payer: First Health Commercial |
$8,683.05
|
| Rate for Payer: Humana Commercial |
$7,769.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,494.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,745.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,742.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,043.24
|
| Rate for Payer: Ohio Health Group HMO |
$6,855.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,828.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,188.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,833.42
|
| Rate for Payer: PHCS Commercial |
$8,774.45
|
| Rate for Payer: United Healthcare All Payer |
$8,043.24
|
|
|
ELEOS STEM SPLINED ST 18*100MM
|
Facility
|
OP
|
$9,140.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.21 |
| Max. Negotiated Rate |
$8,774.45 |
| Rate for Payer: Aetna Commercial |
$7,037.84
|
| Rate for Payer: Anthem Medicaid |
$3,143.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,129.24
|
| Rate for Payer: Cash Price |
$4,570.02
|
| Rate for Payer: Cigna Commercial |
$7,586.24
|
| Rate for Payer: First Health Commercial |
$8,683.05
|
| Rate for Payer: Humana Commercial |
$7,769.04
|
| Rate for Payer: Humana KY Medicaid |
$3,143.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3,175.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,494.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,745.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,742.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,206.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,043.24
|
| Rate for Payer: Ohio Health Group HMO |
$6,855.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,828.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,188.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,833.42
|
| Rate for Payer: PHCS Commercial |
$8,774.45
|
| Rate for Payer: United Healthcare All Payer |
$8,043.24
|
|
|
ELIDEL(PIMECROLIMUS)1%CRM30GM
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
NDC 68682011001
|
| Hospital Charge Code |
25000610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$27.48 |
| Rate for Payer: Aetna Commercial |
$22.04
|
| Rate for Payer: Anthem Medicaid |
$9.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.32
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: First Health Commercial |
$27.19
|
| Rate for Payer: Humana Commercial |
$24.33
|
| Rate for Payer: Humana KY Medicaid |
$9.84
|
| Rate for Payer: Kentucky WC Medicaid |
$9.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.19
|
| Rate for Payer: Ohio Health Group HMO |
$21.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.87
|
| Rate for Payer: PHCS Commercial |
$27.48
|
| Rate for Payer: United Healthcare All Payer |
$25.19
|
|
|
ELIDEL(PIMECROLIMUS)1%CRM30GM
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
NDC 68682011001
|
| Hospital Charge Code |
25000610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$27.48 |
| Rate for Payer: Aetna Commercial |
$22.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.32
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: First Health Commercial |
$27.19
|
| Rate for Payer: Humana Commercial |
$24.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.19
|
| Rate for Payer: Ohio Health Group HMO |
$21.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.87
|
| Rate for Payer: PHCS Commercial |
$27.48
|
| Rate for Payer: United Healthcare All Payer |
$25.19
|
|
|
ELIGARD 22.5MG SYRINGE
|
Facility
|
OP
|
$7,385.13
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25003913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$7,089.72 |
| Rate for Payer: Anthem Medicaid |
$2,539.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,760.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$3,692.56
|
| Rate for Payer: Cash Price |
$3,692.56
|
| Rate for Payer: Cigna Commercial |
$6,129.66
|
| Rate for Payer: First Health Commercial |
$7,015.87
|
| Rate for Payer: Humana Commercial |
$6,277.36
|
| Rate for Payer: Humana KY Medicaid |
$2,539.75
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,565.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,055.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,450.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,590.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,498.91
|
| Rate for Payer: Ohio Health Group HMO |
$5,538.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,477.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$960.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,289.39
|
| Rate for Payer: PHCS Commercial |
$7,089.72
|
| Rate for Payer: United Healthcare All Payer |
$6,498.91
|
| Rate for Payer: Aetna Commercial |
$5,686.55
|
|
|
ELIGARD 22.5MG SYRINGE
|
Facility
|
IP
|
$7,385.13
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25003913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$960.07 |
| Max. Negotiated Rate |
$7,089.72 |
| Rate for Payer: Aetna Commercial |
$5,686.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,760.40
|
| Rate for Payer: Cash Price |
$3,692.56
|
| Rate for Payer: Cigna Commercial |
$6,129.66
|
| Rate for Payer: First Health Commercial |
$7,015.87
|
| Rate for Payer: Humana Commercial |
$6,277.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,055.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,450.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,215.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,498.91
|
| Rate for Payer: Ohio Health Group HMO |
$5,538.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,477.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$960.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,289.39
|
| Rate for Payer: PHCS Commercial |
$7,089.72
|
| Rate for Payer: United Healthcare All Payer |
$6,498.91
|
|
|
ELIGARD 7.5MG (30MG SYRINGE)
|
Facility
|
IP
|
$9,846.84
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,280.09 |
| Max. Negotiated Rate |
$9,452.97 |
| Rate for Payer: Aetna Commercial |
$7,582.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,680.54
|
| Rate for Payer: Cash Price |
$4,923.42
|
| Rate for Payer: Cigna Commercial |
$8,172.88
|
| Rate for Payer: First Health Commercial |
$9,354.50
|
| Rate for Payer: Humana Commercial |
$8,369.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,074.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,266.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,954.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,665.22
|
| Rate for Payer: Ohio Health Group HMO |
$7,385.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,969.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,280.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,052.52
|
| Rate for Payer: PHCS Commercial |
$9,452.97
|
| Rate for Payer: United Healthcare All Payer |
$8,665.22
|
|
|
ELIGARD 7.5MG (30MG SYRINGE)
|
Facility
|
OP
|
$9,846.84
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$9,452.97 |
| Rate for Payer: Aetna Commercial |
$7,582.07
|
| Rate for Payer: Anthem Medicaid |
$3,386.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,680.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$4,923.42
|
| Rate for Payer: Cash Price |
$4,923.42
|
| Rate for Payer: Cigna Commercial |
$8,172.88
|
| Rate for Payer: First Health Commercial |
$9,354.50
|
| Rate for Payer: Humana Commercial |
$8,369.81
|
| Rate for Payer: Humana KY Medicaid |
$3,386.33
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3,420.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,074.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,266.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,454.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,665.22
|
| Rate for Payer: Ohio Health Group HMO |
$7,385.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,969.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,280.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,052.52
|
| Rate for Payer: PHCS Commercial |
$9,452.97
|
| Rate for Payer: United Healthcare All Payer |
$8,665.22
|
|
|
ELIGARD 7.5 MG SYRINGE
|
Facility
|
IP
|
$2,461.71
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25003772
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$320.02 |
| Max. Negotiated Rate |
$2,363.24 |
| Rate for Payer: Aetna Commercial |
$1,895.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,920.13
|
| Rate for Payer: Cash Price |
$1,230.86
|
| Rate for Payer: Cigna Commercial |
$2,043.22
|
| Rate for Payer: First Health Commercial |
$2,338.62
|
| Rate for Payer: Humana Commercial |
$2,092.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,018.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,816.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$738.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,166.30
|
| Rate for Payer: Ohio Health Group HMO |
$1,846.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$492.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$320.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$763.13
|
| Rate for Payer: PHCS Commercial |
$2,363.24
|
| Rate for Payer: United Healthcare All Payer |
$2,166.30
|
|
|
ELIGARD 7.5 MG SYRINGE
|
Facility
|
OP
|
$2,461.71
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25003772
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$2,363.24 |
| Rate for Payer: Aetna Commercial |
$1,895.52
|
| Rate for Payer: Anthem Medicaid |
$846.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,920.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$1,230.86
|
| Rate for Payer: Cash Price |
$1,230.86
|
| Rate for Payer: Cigna Commercial |
$2,043.22
|
| Rate for Payer: First Health Commercial |
$2,338.62
|
| Rate for Payer: Humana Commercial |
$2,092.45
|
| Rate for Payer: Humana KY Medicaid |
$846.58
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$855.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,018.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,816.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$863.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,166.30
|
| Rate for Payer: Ohio Health Group HMO |
$1,846.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$492.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$320.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$763.13
|
| Rate for Payer: PHCS Commercial |
$2,363.24
|
| Rate for Payer: United Healthcare All Payer |
$2,166.30
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Facility
|
OP
|
$903.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636T0084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.44 |
| Max. Negotiated Rate |
$867.24 |
| Rate for Payer: Aetna Commercial |
$695.60
|
| Rate for Payer: Anthem Medicaid |
$310.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$704.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cigna Commercial |
$749.81
|
| Rate for Payer: First Health Commercial |
$858.21
|
| Rate for Payer: Humana Commercial |
$767.87
|
| Rate for Payer: Humana KY Medicaid |
$310.67
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$313.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$740.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$666.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$316.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$794.97
|
| Rate for Payer: Ohio Health Group HMO |
$677.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.05
|
| Rate for Payer: PHCS Commercial |
$867.24
|
| Rate for Payer: United Healthcare All Payer |
$794.97
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Facility
|
OP
|
$903.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.44 |
| Max. Negotiated Rate |
$867.24 |
| Rate for Payer: Aetna Commercial |
$695.60
|
| Rate for Payer: Anthem Medicaid |
$310.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$704.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cigna Commercial |
$749.81
|
| Rate for Payer: First Health Commercial |
$858.21
|
| Rate for Payer: Humana Commercial |
$767.87
|
| Rate for Payer: Humana KY Medicaid |
$310.67
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$313.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$740.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$666.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$316.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$794.97
|
| Rate for Payer: Ohio Health Group HMO |
$677.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.05
|
| Rate for Payer: PHCS Commercial |
$867.24
|
| Rate for Payer: United Healthcare All Payer |
$794.97
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Facility
|
IP
|
$14,770.21
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002641
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,920.13 |
| Max. Negotiated Rate |
$14,179.40 |
| Rate for Payer: Aetna Commercial |
$11,373.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,520.76
|
| Rate for Payer: Cash Price |
$7,385.10
|
| Rate for Payer: Cigna Commercial |
$12,259.27
|
| Rate for Payer: First Health Commercial |
$14,031.70
|
| Rate for Payer: Humana Commercial |
$12,554.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,111.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,900.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,431.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,997.78
|
| Rate for Payer: Ohio Health Group HMO |
$11,077.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,954.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,920.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,578.77
|
| Rate for Payer: PHCS Commercial |
$14,179.40
|
| Rate for Payer: United Healthcare All Payer |
$12,997.78
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Professional
|
Both
|
$903.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.26 |
| Max. Negotiated Rate |
$903.38 |
| Rate for Payer: Aetna Commercial |
$190.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$903.38
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.39
|
| Rate for Payer: Multiplan PHCS |
$542.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$632.37
|
| Rate for Payer: UHCCP Medicaid |
$316.18
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Facility
|
IP
|
$903.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.44 |
| Max. Negotiated Rate |
$867.24 |
| Rate for Payer: Aetna Commercial |
$695.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$704.64
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cigna Commercial |
$749.81
|
| Rate for Payer: First Health Commercial |
$858.21
|
| Rate for Payer: Humana Commercial |
$767.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$740.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$666.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$794.97
|
| Rate for Payer: Ohio Health Group HMO |
$677.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.05
|
| Rate for Payer: PHCS Commercial |
$867.24
|
| Rate for Payer: United Healthcare All Payer |
$794.97
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Facility
|
OP
|
$14,770.21
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002641
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$14,179.40 |
| Rate for Payer: Aetna Commercial |
$11,373.06
|
| Rate for Payer: Anthem Medicaid |
$5,079.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,520.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$7,385.10
|
| Rate for Payer: Cash Price |
$7,385.10
|
| Rate for Payer: Cigna Commercial |
$12,259.27
|
| Rate for Payer: First Health Commercial |
$14,031.70
|
| Rate for Payer: Humana Commercial |
$12,554.68
|
| Rate for Payer: Humana KY Medicaid |
$5,079.48
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,131.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,111.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,900.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,181.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,997.78
|
| Rate for Payer: Ohio Health Group HMO |
$11,077.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,954.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,920.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,578.77
|
| Rate for Payer: PHCS Commercial |
$14,179.40
|
| Rate for Payer: United Healthcare All Payer |
$12,997.78
|
|
|
ELIGARD EA 7.5MG[45 MG SYR]
|
Facility
|
IP
|
$903.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636T0084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.44 |
| Max. Negotiated Rate |
$867.24 |
| Rate for Payer: Aetna Commercial |
$695.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$704.64
|
| Rate for Payer: Cash Price |
$451.69
|
| Rate for Payer: Cigna Commercial |
$749.81
|
| Rate for Payer: First Health Commercial |
$858.21
|
| Rate for Payer: Humana Commercial |
$767.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$740.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$666.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$794.97
|
| Rate for Payer: Ohio Health Group HMO |
$677.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.05
|
| Rate for Payer: PHCS Commercial |
$867.24
|
| Rate for Payer: United Healthcare All Payer |
$794.97
|
|
|
ELIMITE(PERMETHRIN)5%CREAM60GM
|
Facility
|
IP
|
$3.02
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
25000611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.36
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna Commercial |
$2.51
|
| Rate for Payer: First Health Commercial |
$2.87
|
| Rate for Payer: Humana Commercial |
$2.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.66
|
| Rate for Payer: Ohio Health Group HMO |
$2.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.94
|
| Rate for Payer: PHCS Commercial |
$2.90
|
| Rate for Payer: United Healthcare All Payer |
$2.66
|
|
