|
ELIMITE(PERMETHRIN)5%CREAM60GM
|
Facility
|
OP
|
$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 Medicaid |
$1.04
|
| 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: Humana KY Medicaid |
$1.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1.05
|
| 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: Molina Healthcare Medicaid |
$1.06
|
| 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
|
|
|
ELIQUIS 2.5MG TABLET
|
Facility
|
IP
|
$26.91
|
|
|
Service Code
|
NDC 3089331
|
| Hospital Charge Code |
25000612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$20.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.99
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cigna Commercial |
$22.34
|
| Rate for Payer: First Health Commercial |
$25.56
|
| Rate for Payer: Humana Commercial |
$22.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.68
|
| Rate for Payer: Ohio Health Group HMO |
$20.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.34
|
| Rate for Payer: PHCS Commercial |
$25.83
|
| Rate for Payer: United Healthcare All Payer |
$23.68
|
|
|
ELIQUIS 2.5MG TABLET
|
Facility
|
OP
|
$26.91
|
|
|
Service Code
|
NDC 3089331
|
| Hospital Charge Code |
25000612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$20.72
|
| Rate for Payer: Anthem Medicaid |
$9.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.99
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cigna Commercial |
$22.34
|
| Rate for Payer: First Health Commercial |
$25.56
|
| Rate for Payer: Humana Commercial |
$22.87
|
| Rate for Payer: Humana KY Medicaid |
$9.25
|
| Rate for Payer: Kentucky WC Medicaid |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.68
|
| Rate for Payer: Ohio Health Group HMO |
$20.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.34
|
| Rate for Payer: PHCS Commercial |
$25.83
|
| Rate for Payer: United Healthcare All Payer |
$23.68
|
|
|
ELIQUIS 5MG TABLET
|
Facility
|
OP
|
$26.91
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
25000613
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$20.72
|
| Rate for Payer: Anthem Medicaid |
$9.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.99
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cigna Commercial |
$22.34
|
| Rate for Payer: First Health Commercial |
$25.56
|
| Rate for Payer: Humana Commercial |
$22.87
|
| Rate for Payer: Humana KY Medicaid |
$9.25
|
| Rate for Payer: Kentucky WC Medicaid |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.68
|
| Rate for Payer: Ohio Health Group HMO |
$20.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.34
|
| Rate for Payer: PHCS Commercial |
$25.83
|
| Rate for Payer: United Healthcare All Payer |
$23.68
|
|
|
ELIQUIS 5MG TABLET
|
Facility
|
IP
|
$26.91
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
25000613
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$20.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.99
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cigna Commercial |
$22.34
|
| Rate for Payer: First Health Commercial |
$25.56
|
| Rate for Payer: Humana Commercial |
$22.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.68
|
| Rate for Payer: Ohio Health Group HMO |
$20.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.34
|
| Rate for Payer: PHCS Commercial |
$25.83
|
| Rate for Payer: United Healthcare All Payer |
$23.68
|
|
|
ELITEK 1.5 MG VL (0.5 MG JCODE
|
Facility
|
IP
|
$2,824.52
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.19 |
| Max. Negotiated Rate |
$2,711.54 |
| Rate for Payer: Aetna Commercial |
$2,174.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,203.13
|
| Rate for Payer: Cash Price |
$1,412.26
|
| Rate for Payer: Cigna Commercial |
$2,344.35
|
| Rate for Payer: First Health Commercial |
$2,683.29
|
| Rate for Payer: Humana Commercial |
$2,400.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,316.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,084.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$847.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,485.58
|
| Rate for Payer: Ohio Health Group HMO |
$2,118.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$564.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$367.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$875.60
|
| Rate for Payer: PHCS Commercial |
$2,711.54
|
| Rate for Payer: United Healthcare All Payer |
$2,485.58
|
|
|
ELITEK 1.5 MG VL (0.5 MG JCODE
|
Facility
|
OP
|
$2,824.52
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.19 |
| Max. Negotiated Rate |
$2,711.54 |
| Rate for Payer: Aetna Commercial |
$2,174.88
|
| Rate for Payer: Anthem Medicaid |
$971.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$367.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,203.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$514.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$495.81
|
| Rate for Payer: Cash Price |
$1,412.26
|
| Rate for Payer: Cash Price |
$1,412.26
|
| Rate for Payer: Cigna Commercial |
$2,344.35
|
| Rate for Payer: First Health Commercial |
$2,683.29
|
| Rate for Payer: Humana Commercial |
$2,400.84
|
| Rate for Payer: Humana KY Medicaid |
$971.35
|
| Rate for Payer: Humana Medicare Advantage |
$367.27
|
| Rate for Payer: Kentucky WC Medicaid |
$981.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,316.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,084.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$440.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$990.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,485.58
|
| Rate for Payer: Ohio Health Group HMO |
$2,118.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$564.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$367.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$875.60
|
| Rate for Payer: PHCS Commercial |
$2,711.54
|
| Rate for Payer: United Healthcare All Payer |
$2,485.58
|
|
|
ELITEK 7.5MG VL (0.5MG J CODE)
|
Facility
|
OP
|
$7,122.57
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.27 |
| Max. Negotiated Rate |
$6,837.67 |
| Rate for Payer: Anthem Medicaid |
$2,449.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$367.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,555.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$514.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$495.81
|
| Rate for Payer: Cash Price |
$3,561.28
|
| Rate for Payer: Cash Price |
$3,561.28
|
| Rate for Payer: Cigna Commercial |
$5,911.73
|
| Rate for Payer: First Health Commercial |
$6,766.44
|
| Rate for Payer: Humana Commercial |
$6,054.18
|
| Rate for Payer: Humana KY Medicaid |
$2,449.45
|
| Rate for Payer: Humana Medicare Advantage |
$367.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,474.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,840.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,256.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$440.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,498.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,267.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,341.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,424.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$925.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$6,837.67
|
| Rate for Payer: United Healthcare All Payer |
$6,267.86
|
| Rate for Payer: Aetna Commercial |
$5,484.38
|
|
|
ELITEK 7.5MG VL (0.5MG J CODE)
|
Facility
|
IP
|
$7,122.57
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$925.93 |
| Max. Negotiated Rate |
$6,837.67 |
| Rate for Payer: Aetna Commercial |
$5,484.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,555.60
|
| Rate for Payer: Cash Price |
$3,561.28
|
| Rate for Payer: Cigna Commercial |
$5,911.73
|
| Rate for Payer: First Health Commercial |
$6,766.44
|
| Rate for Payer: Humana Commercial |
$6,054.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,840.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,256.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,136.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,267.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,341.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,424.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$925.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$6,837.67
|
| Rate for Payer: United Healthcare All Payer |
$6,267.86
|
|
|
ELMIRON(PENTPOLYSULF)100MG CAP
|
Facility
|
IP
|
$28.30
|
|
|
Service Code
|
NDC 50458009801
|
| Hospital Charge Code |
25000614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$27.17 |
| Rate for Payer: Humana Commercial |
$24.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.90
|
| Rate for Payer: Ohio Health Group HMO |
$21.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.77
|
| Rate for Payer: PHCS Commercial |
$27.17
|
| Rate for Payer: United Healthcare All Payer |
$24.90
|
| Rate for Payer: Aetna Commercial |
$21.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.07
|
| Rate for Payer: Cash Price |
$14.15
|
| Rate for Payer: Cigna Commercial |
$23.49
|
| Rate for Payer: First Health Commercial |
$26.88
|
|
|
ELMIRON(PENTPOLYSULF)100MG CAP
|
Facility
|
OP
|
$28.30
|
|
|
Service Code
|
NDC 50458009801
|
| Hospital Charge Code |
25000614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$27.17 |
| Rate for Payer: Aetna Commercial |
$21.79
|
| Rate for Payer: Anthem Medicaid |
$9.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.07
|
| Rate for Payer: Cash Price |
$14.15
|
| Rate for Payer: Cigna Commercial |
$23.49
|
| Rate for Payer: First Health Commercial |
$26.88
|
| Rate for Payer: Humana Commercial |
$24.06
|
| Rate for Payer: Humana KY Medicaid |
$9.73
|
| Rate for Payer: Kentucky WC Medicaid |
$9.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.90
|
| Rate for Payer: Ohio Health Group HMO |
$21.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.77
|
| Rate for Payer: PHCS Commercial |
$27.17
|
| Rate for Payer: United Healthcare All Payer |
$24.90
|
|
|
ELM TREE IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000939
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
ELM TREE IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000939
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
ELOCON (MOMETSONE) FURDAT 15GM
|
Facility
|
OP
|
$6.17
|
|
|
Service Code
|
NDC 713063415
|
| Hospital Charge Code |
25000615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.92 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Anthem Medicaid |
$2.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.81
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Cigna Commercial |
$5.12
|
| Rate for Payer: First Health Commercial |
$5.86
|
| Rate for Payer: Humana Commercial |
$5.24
|
| Rate for Payer: Humana KY Medicaid |
$2.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.43
|
| Rate for Payer: Ohio Health Group HMO |
$4.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.91
|
| Rate for Payer: PHCS Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Payer |
$5.43
|
|
|
ELOCON (MOMETSONE) FURDAT 15GM
|
Facility
|
IP
|
$6.17
|
|
|
Service Code
|
NDC 713063415
|
| Hospital Charge Code |
25000615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.92 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.81
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Cigna Commercial |
$5.12
|
| Rate for Payer: First Health Commercial |
$5.86
|
| Rate for Payer: Humana Commercial |
$5.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.43
|
| Rate for Payer: Ohio Health Group HMO |
$4.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.91
|
| Rate for Payer: PHCS Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Payer |
$5.43
|
|
|
ELOTUZUMAB 1mg (300mg SDV)
|
Facility
|
OP
|
$12,159.17
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$11,672.80 |
| Rate for Payer: Aetna Commercial |
$9,362.56
|
| Rate for Payer: Anthem Medicaid |
$4,181.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,484.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.96
|
| Rate for Payer: Cash Price |
$6,079.58
|
| Rate for Payer: Cash Price |
$6,079.58
|
| Rate for Payer: Cigna Commercial |
$10,092.11
|
| Rate for Payer: First Health Commercial |
$11,551.21
|
| Rate for Payer: Humana Commercial |
$10,335.29
|
| Rate for Payer: Humana KY Medicaid |
$4,181.54
|
| Rate for Payer: Humana Medicare Advantage |
$7.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,224.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,970.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,973.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,265.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,700.07
|
| Rate for Payer: Ohio Health Group HMO |
$9,119.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,431.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,580.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,769.34
|
| Rate for Payer: PHCS Commercial |
$11,672.80
|
| Rate for Payer: United Healthcare All Payer |
$10,700.07
|
|
|
ELOTUZUMAB 1mg (300mg SDV)
|
Facility
|
IP
|
$12,159.17
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,580.69 |
| Max. Negotiated Rate |
$11,672.80 |
| Rate for Payer: Aetna Commercial |
$9,362.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,484.15
|
| Rate for Payer: Cash Price |
$6,079.58
|
| Rate for Payer: Cigna Commercial |
$10,092.11
|
| Rate for Payer: First Health Commercial |
$11,551.21
|
| Rate for Payer: Humana Commercial |
$10,335.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,970.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,973.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,647.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,700.07
|
| Rate for Payer: Ohio Health Group HMO |
$9,119.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,431.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,580.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,769.34
|
| Rate for Payer: PHCS Commercial |
$11,672.80
|
| Rate for Payer: United Healthcare All Payer |
$10,700.07
|
|
|
ELOTUZUMAB 1mg (400mg SDV)
|
Facility
|
OP
|
$16,212.06
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$15,563.58 |
| Rate for Payer: Aetna Commercial |
$12,483.29
|
| Rate for Payer: Anthem Medicaid |
$5,575.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,645.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.96
|
| Rate for Payer: Cash Price |
$8,106.03
|
| Rate for Payer: Cash Price |
$8,106.03
|
| Rate for Payer: Cigna Commercial |
$13,456.01
|
| Rate for Payer: First Health Commercial |
$15,401.46
|
| Rate for Payer: Humana Commercial |
$13,780.25
|
| Rate for Payer: Humana KY Medicaid |
$5,575.33
|
| Rate for Payer: Humana Medicare Advantage |
$7.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,632.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,293.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,964.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,687.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,266.61
|
| Rate for Payer: Ohio Health Group HMO |
$12,159.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,242.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,107.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,025.74
|
| Rate for Payer: PHCS Commercial |
$15,563.58
|
| Rate for Payer: United Healthcare All Payer |
$14,266.61
|
|
|
ELOTUZUMAB 1mg (400mg SDV)
|
Facility
|
IP
|
$16,212.06
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,107.57 |
| Max. Negotiated Rate |
$15,563.58 |
| Rate for Payer: Aetna Commercial |
$12,483.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,645.41
|
| Rate for Payer: Cash Price |
$8,106.03
|
| Rate for Payer: Cigna Commercial |
$13,456.01
|
| Rate for Payer: First Health Commercial |
$15,401.46
|
| Rate for Payer: Humana Commercial |
$13,780.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,293.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,964.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,863.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,266.61
|
| Rate for Payer: Ohio Health Group HMO |
$12,159.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,242.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,107.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,025.74
|
| Rate for Payer: PHCS Commercial |
$15,563.58
|
| Rate for Payer: United Healthcare All Payer |
$14,266.61
|
|
|
ELOXATIN 0.5MG 100MGVIAL
|
Facility
|
IP
|
$545.00
|
|
|
Service Code
|
HCPCS J9263
|
| Hospital Charge Code |
25002649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$523.20 |
| Rate for Payer: Aetna Commercial |
$419.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.10
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$452.35
|
| Rate for Payer: First Health Commercial |
$517.75
|
| Rate for Payer: Humana Commercial |
$463.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.60
|
| Rate for Payer: Ohio Health Group HMO |
$408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.95
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
|
ELOXATIN 0.5MG 100MGVIAL
|
Facility
|
OP
|
$545.00
|
|
|
Service Code
|
HCPCS J9263
|
| Hospital Charge Code |
25002649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$523.20 |
| Rate for Payer: Aetna Commercial |
$419.65
|
| Rate for Payer: Anthem Medicaid |
$187.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.10
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$452.35
|
| Rate for Payer: First Health Commercial |
$517.75
|
| Rate for Payer: Humana Commercial |
$463.25
|
| Rate for Payer: Humana KY Medicaid |
$187.43
|
| Rate for Payer: Kentucky WC Medicaid |
$189.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.60
|
| Rate for Payer: Ohio Health Group HMO |
$408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.95
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
|
ELOXATIN 0.5 MG (50 MG VL)
|
Facility
|
IP
|
$272.50
|
|
|
Service Code
|
HCPCS J9263
|
| Hospital Charge Code |
25002650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.42 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: Aetna Commercial |
$209.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$212.55
|
| Rate for Payer: Cash Price |
$136.25
|
| Rate for Payer: Cigna Commercial |
$226.18
|
| Rate for Payer: First Health Commercial |
$258.88
|
| Rate for Payer: Humana Commercial |
$231.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$223.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$201.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$239.80
|
| Rate for Payer: Ohio Health Group HMO |
$204.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.48
|
| Rate for Payer: PHCS Commercial |
$261.60
|
| Rate for Payer: United Healthcare All Payer |
$239.80
|
|
|
ELOXATIN 0.5 MG (50 MG VL)
|
Facility
|
OP
|
$272.50
|
|
|
Service Code
|
HCPCS J9263
|
| Hospital Charge Code |
25002650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.42 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: Aetna Commercial |
$209.82
|
| Rate for Payer: Anthem Medicaid |
$93.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$212.55
|
| Rate for Payer: Cash Price |
$136.25
|
| Rate for Payer: Cigna Commercial |
$226.18
|
| Rate for Payer: First Health Commercial |
$258.88
|
| Rate for Payer: Humana Commercial |
$231.62
|
| Rate for Payer: Humana KY Medicaid |
$93.71
|
| Rate for Payer: Kentucky WC Medicaid |
$94.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$223.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$201.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$95.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$239.80
|
| Rate for Payer: Ohio Health Group HMO |
$204.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.48
|
| Rate for Payer: PHCS Commercial |
$261.60
|
| Rate for Payer: United Healthcare All Payer |
$239.80
|
|
|
ELUVIA 6*100*130
|
Facility
|
IP
|
$12,771.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,660.33 |
| Max. Negotiated Rate |
$12,260.88 |
| Rate for Payer: Aetna Commercial |
$9,834.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,961.96
|
| Rate for Payer: Cash Price |
$6,385.88
|
| Rate for Payer: Cigna Commercial |
$10,600.55
|
| Rate for Payer: First Health Commercial |
$12,133.16
|
| Rate for Payer: Humana Commercial |
$10,855.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,472.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,425.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,831.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,239.14
|
| Rate for Payer: Ohio Health Group HMO |
$9,578.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,554.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,660.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,959.24
|
| Rate for Payer: PHCS Commercial |
$12,260.88
|
| Rate for Payer: United Healthcare All Payer |
$11,239.14
|
|
|
ELUVIA 6*100*130
|
Facility
|
OP
|
$12,771.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,660.33 |
| Max. Negotiated Rate |
$12,260.88 |
| Rate for Payer: Aetna Commercial |
$9,834.25
|
| Rate for Payer: Anthem Medicaid |
$4,392.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,961.96
|
| Rate for Payer: Cash Price |
$6,385.88
|
| Rate for Payer: Cigna Commercial |
$10,600.55
|
| Rate for Payer: First Health Commercial |
$12,133.16
|
| Rate for Payer: Humana Commercial |
$10,855.99
|
| Rate for Payer: Humana KY Medicaid |
$4,392.20
|
| Rate for Payer: Kentucky WC Medicaid |
$4,436.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,472.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,425.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,831.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,480.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,239.14
|
| Rate for Payer: Ohio Health Group HMO |
$9,578.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,554.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,660.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,959.24
|
| Rate for Payer: PHCS Commercial |
$12,260.88
|
| Rate for Payer: United Healthcare All Payer |
$11,239.14
|
|
