|
ETHYOL(AMIFOSTINE) 500MG/10ML
|
Facility
|
IP
|
$5,839.18
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
25001840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$759.09 |
| Max. Negotiated Rate |
$5,605.61 |
| Rate for Payer: Aetna Commercial |
$4,496.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,554.56
|
| Rate for Payer: Cash Price |
$2,919.59
|
| Rate for Payer: Cigna Commercial |
$4,846.52
|
| Rate for Payer: First Health Commercial |
$5,547.22
|
| Rate for Payer: Humana Commercial |
$4,963.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,788.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,309.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,751.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,138.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,379.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,167.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,810.15
|
| Rate for Payer: PHCS Commercial |
$5,605.61
|
| Rate for Payer: United Healthcare All Payer |
$5,138.48
|
|
|
ETHYOL SQ 500MG VIAL
|
Facility
|
OP
|
$5,839.18
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
25001841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$759.09 |
| Max. Negotiated Rate |
$5,605.61 |
| Rate for Payer: Aetna Commercial |
$4,496.17
|
| Rate for Payer: Anthem Medicaid |
$2,008.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,554.56
|
| Rate for Payer: Cash Price |
$2,919.59
|
| Rate for Payer: Cigna Commercial |
$4,846.52
|
| Rate for Payer: First Health Commercial |
$5,547.22
|
| Rate for Payer: Humana Commercial |
$4,963.30
|
| Rate for Payer: Humana KY Medicaid |
$2,008.09
|
| Rate for Payer: Kentucky WC Medicaid |
$2,028.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,788.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,309.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,751.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,048.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,138.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,379.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,167.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,810.15
|
| Rate for Payer: PHCS Commercial |
$5,605.61
|
| Rate for Payer: United Healthcare All Payer |
$5,138.48
|
|
|
ETHYOL SQ 500MG VIAL
|
Facility
|
IP
|
$5,839.18
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
25001841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$759.09 |
| Max. Negotiated Rate |
$5,605.61 |
| Rate for Payer: Aetna Commercial |
$4,496.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,554.56
|
| Rate for Payer: Cash Price |
$2,919.59
|
| Rate for Payer: Cigna Commercial |
$4,846.52
|
| Rate for Payer: First Health Commercial |
$5,547.22
|
| Rate for Payer: Humana Commercial |
$4,963.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,788.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,309.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,751.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,138.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,379.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,167.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,810.15
|
| Rate for Payer: PHCS Commercial |
$5,605.61
|
| Rate for Payer: United Healthcare All Payer |
$5,138.48
|
|
|
ETOPOSIDE 10MG (1000MG MDV)
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
25004037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.27
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna Commercial |
$5.61
|
| Rate for Payer: First Health Commercial |
$6.42
|
| Rate for Payer: Humana Commercial |
$5.75
|
| Rate for Payer: Humana KY Medicaid |
$2.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.95
|
| Rate for Payer: Ohio Health Group HMO |
$5.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.10
|
| Rate for Payer: PHCS Commercial |
$6.49
|
| Rate for Payer: United Healthcare All Payer |
$5.95
|
| Rate for Payer: Aetna Commercial |
$5.21
|
| Rate for Payer: Anthem Medicaid |
$2.32
|
|
|
ETOPOSIDE 10MG (1000MG MDV)
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
25004037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Aetna Commercial |
$5.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.27
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna Commercial |
$5.61
|
| Rate for Payer: First Health Commercial |
$6.42
|
| Rate for Payer: Humana Commercial |
$5.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.95
|
| Rate for Payer: Ohio Health Group HMO |
$5.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.10
|
| Rate for Payer: PHCS Commercial |
$6.49
|
| Rate for Payer: United Healthcare All Payer |
$5.95
|
|
|
ETOPOSIDE 10MG (100MG MDV)
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
25004035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna Commercial |
$4.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.38
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cigna Commercial |
$4.66
|
| Rate for Payer: First Health Commercial |
$5.33
|
| Rate for Payer: Humana Commercial |
$4.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.94
|
| Rate for Payer: Ohio Health Group HMO |
$4.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.74
|
| Rate for Payer: PHCS Commercial |
$5.39
|
| Rate for Payer: United Healthcare All Payer |
$4.94
|
|
|
ETOPOSIDE 10MG (100MG MDV)
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
25004035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna Commercial |
$4.32
|
| Rate for Payer: Anthem Medicaid |
$1.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.38
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cigna Commercial |
$4.66
|
| Rate for Payer: First Health Commercial |
$5.33
|
| Rate for Payer: Humana Commercial |
$4.77
|
| Rate for Payer: Humana KY Medicaid |
$1.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.94
|
| Rate for Payer: Ohio Health Group HMO |
$4.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.74
|
| Rate for Payer: PHCS Commercial |
$5.39
|
| Rate for Payer: United Healthcare All Payer |
$4.94
|
|
|
ETOPOSIDE 10MG (500MG MDV)
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
25004036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Aetna Commercial |
$5.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.27
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna Commercial |
$5.61
|
| Rate for Payer: First Health Commercial |
$6.42
|
| Rate for Payer: Humana Commercial |
$5.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.95
|
| Rate for Payer: Ohio Health Group HMO |
$5.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.10
|
| Rate for Payer: PHCS Commercial |
$6.49
|
| Rate for Payer: United Healthcare All Payer |
$5.95
|
|
|
ETOPOSIDE 10MG (500MG MDV)
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
25004036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Aetna Commercial |
$5.21
|
| Rate for Payer: Anthem Medicaid |
$2.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.27
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna Commercial |
$5.61
|
| Rate for Payer: First Health Commercial |
$6.42
|
| Rate for Payer: Humana Commercial |
$5.75
|
| Rate for Payer: Humana KY Medicaid |
$2.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.95
|
| Rate for Payer: Ohio Health Group HMO |
$5.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.10
|
| Rate for Payer: PHCS Commercial |
$6.49
|
| Rate for Payer: United Healthcare All Payer |
$5.95
|
|
|
EUCERIN CREAM 120 GM
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 72140000022
|
| Hospital Charge Code |
25000639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem Medicaid |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Humana KY Medicaid |
$0.09
|
| Rate for Payer: Kentucky WC Medicaid |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
EUCERIN CREAM 120 GM
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 72140000022
|
| Hospital Charge Code |
25000639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Facility
|
OP
|
$2,538.39
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
636T0076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.30 |
| Max. Negotiated Rate |
$2,436.85 |
| Rate for Payer: Aetna Commercial |
$1,954.56
|
| Rate for Payer: Anthem Medicaid |
$872.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$127.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,979.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$178.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.86
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cigna Commercial |
$2,106.86
|
| Rate for Payer: First Health Commercial |
$2,411.47
|
| Rate for Payer: Humana Commercial |
$2,157.63
|
| Rate for Payer: Humana KY Medicaid |
$872.95
|
| Rate for Payer: Humana Medicare Advantage |
$127.30
|
| Rate for Payer: Kentucky WC Medicaid |
$881.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,081.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,873.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$890.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,233.78
|
| Rate for Payer: Ohio Health Group HMO |
$1,903.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$507.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$329.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.90
|
| Rate for Payer: PHCS Commercial |
$2,436.85
|
| Rate for Payer: United Healthcare All Payer |
$2,233.78
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Facility
|
IP
|
$2,538.39
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
63600076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.99 |
| Max. Negotiated Rate |
$2,436.85 |
| Rate for Payer: Aetna Commercial |
$1,954.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,979.94
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cigna Commercial |
$2,106.86
|
| Rate for Payer: First Health Commercial |
$2,411.47
|
| Rate for Payer: Humana Commercial |
$2,157.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,081.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,873.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$761.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,233.78
|
| Rate for Payer: Ohio Health Group HMO |
$1,903.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$507.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$329.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.90
|
| Rate for Payer: PHCS Commercial |
$2,436.85
|
| Rate for Payer: United Healthcare All Payer |
$2,233.78
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Facility
|
IP
|
$1,965.42
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
25002488
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$255.50 |
| Max. Negotiated Rate |
$1,886.80 |
| Rate for Payer: Aetna Commercial |
$1,513.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,533.03
|
| Rate for Payer: Cash Price |
$982.71
|
| Rate for Payer: Cigna Commercial |
$1,631.30
|
| Rate for Payer: First Health Commercial |
$1,867.15
|
| Rate for Payer: Humana Commercial |
$1,670.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,611.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,450.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,729.57
|
| Rate for Payer: Ohio Health Group HMO |
$1,474.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$609.28
|
| Rate for Payer: PHCS Commercial |
$1,886.80
|
| Rate for Payer: United Healthcare All Payer |
$1,729.57
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Professional
|
Both
|
$2,538.39
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
63600076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,538.39 |
| Rate for Payer: Aetna Commercial |
$189.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,538.39
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$196.45
|
| Rate for Payer: Multiplan PHCS |
$1,523.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,776.87
|
| Rate for Payer: UHCCP Medicaid |
$888.44
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Facility
|
OP
|
$1,965.42
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
25002488
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.30 |
| Max. Negotiated Rate |
$1,886.80 |
| Rate for Payer: Aetna Commercial |
$1,513.37
|
| Rate for Payer: Anthem Medicaid |
$675.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$127.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,533.03
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$178.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.86
|
| Rate for Payer: Cash Price |
$982.71
|
| Rate for Payer: Cash Price |
$982.71
|
| Rate for Payer: Cigna Commercial |
$1,631.30
|
| Rate for Payer: First Health Commercial |
$1,867.15
|
| Rate for Payer: Humana Commercial |
$1,670.61
|
| Rate for Payer: Humana KY Medicaid |
$675.91
|
| Rate for Payer: Humana Medicare Advantage |
$127.30
|
| Rate for Payer: Kentucky WC Medicaid |
$682.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,611.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,450.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$689.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,729.57
|
| Rate for Payer: Ohio Health Group HMO |
$1,474.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$609.28
|
| Rate for Payer: PHCS Commercial |
$1,886.80
|
| Rate for Payer: United Healthcare All Payer |
$1,729.57
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Facility
|
OP
|
$2,538.39
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
63600076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.30 |
| Max. Negotiated Rate |
$2,436.85 |
| Rate for Payer: Aetna Commercial |
$1,954.56
|
| Rate for Payer: Anthem Medicaid |
$872.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$127.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,979.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$178.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.86
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cigna Commercial |
$2,106.86
|
| Rate for Payer: First Health Commercial |
$2,411.47
|
| Rate for Payer: Humana Commercial |
$2,157.63
|
| Rate for Payer: Humana KY Medicaid |
$872.95
|
| Rate for Payer: Humana Medicare Advantage |
$127.30
|
| Rate for Payer: Kentucky WC Medicaid |
$881.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,081.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,873.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$890.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,233.78
|
| Rate for Payer: Ohio Health Group HMO |
$1,903.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$507.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$329.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.90
|
| Rate for Payer: PHCS Commercial |
$2,436.85
|
| Rate for Payer: United Healthcare All Payer |
$2,233.78
|
|
|
EUFLEXXA SYRINGE 20MG/2ML
|
Facility
|
IP
|
$2,538.39
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
636T0076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.99 |
| Max. Negotiated Rate |
$2,436.85 |
| Rate for Payer: Aetna Commercial |
$1,954.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,979.94
|
| Rate for Payer: Cash Price |
$1,269.19
|
| Rate for Payer: Cigna Commercial |
$2,106.86
|
| Rate for Payer: First Health Commercial |
$2,411.47
|
| Rate for Payer: Humana Commercial |
$2,157.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,081.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,873.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$761.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,233.78
|
| Rate for Payer: Ohio Health Group HMO |
$1,903.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$507.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$329.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.90
|
| Rate for Payer: PHCS Commercial |
$2,436.85
|
| Rate for Payer: United Healthcare All Payer |
$2,233.78
|
|
|
EVAC RPR A-BIILIAC NDGFT
|
Facility
|
OP
|
$1,770.00
|
|
|
Service Code
|
HCPCS 34705
|
| Hospital Charge Code |
76101347
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$230.10 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$1,362.90
|
| Rate for Payer: Anthem Medicaid |
$608.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,380.60
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$1,469.10
|
| Rate for Payer: First Health Commercial |
$1,681.50
|
| Rate for Payer: Humana Commercial |
$1,504.50
|
| Rate for Payer: Humana KY Medicaid |
$608.70
|
| Rate for Payer: Kentucky WC Medicaid |
$614.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$620.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,557.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,327.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.70
|
| Rate for Payer: PHCS Commercial |
$1,699.20
|
| Rate for Payer: United Healthcare All Payer |
$1,557.60
|
|
|
EVAC RPR A-BIILIAC NDGFT
|
Facility
|
IP
|
$1,770.00
|
|
|
Service Code
|
HCPCS 34705
|
| Hospital Charge Code |
76101347
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$230.10 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$1,362.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,380.60
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$1,469.10
|
| Rate for Payer: First Health Commercial |
$1,681.50
|
| Rate for Payer: Humana Commercial |
$1,504.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,557.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,327.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.70
|
| Rate for Payer: PHCS Commercial |
$1,699.20
|
| Rate for Payer: United Healthcare All Payer |
$1,557.60
|
|
|
EVAC RPR A-BIILIAC NDGFT
|
Professional
|
Both
|
$1,770.00
|
|
|
Service Code
|
HCPCS 34705
|
| Hospital Charge Code |
76101347
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$619.50 |
| Max. Negotiated Rate |
$2,810.90 |
| Rate for Payer: Anthem Medicaid |
$1,228.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,770.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$2,810.90
|
| Rate for Payer: Humana Medicaid |
$1,228.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,050.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,253.56
|
| Rate for Payer: Molina Healthcare Passport |
$1,228.98
|
| Rate for Payer: Multiplan PHCS |
$1,062.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,239.00
|
| Rate for Payer: UHCCP Medicaid |
$619.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,241.27
|
|
|
EVAC RPR A-BIILIAC NDGFT(P
|
Professional
|
Both
|
$1,770.00
|
|
|
Service Code
|
HCPCS 34705
|
| Hospital Charge Code |
761P1347
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$619.50 |
| Max. Negotiated Rate |
$2,810.90 |
| Rate for Payer: Anthem Medicaid |
$1,228.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,770.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Cigna Commercial |
$2,810.90
|
| Rate for Payer: Humana Medicaid |
$1,228.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,050.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,253.56
|
| Rate for Payer: Molina Healthcare Passport |
$1,228.98
|
| Rate for Payer: Multiplan PHCS |
$1,062.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,239.00
|
| Rate for Payer: UHCCP Medicaid |
$619.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,241.27
|
|
|
EVAC SUBUNGUAL HEMATOMA
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
HCPCS 11740
|
| Hospital Charge Code |
76100098
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$15.92 |
| Max. Negotiated Rate |
$269.00 |
| Rate for Payer: Aetna Commercial |
$45.62
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$15.92
|
| Rate for Payer: Anthem Medicaid |
$17.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$269.00
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$55.39
|
| Rate for Payer: Healthspan PPO |
$49.74
|
| Rate for Payer: Humana Medicaid |
$17.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.40
|
| Rate for Payer: Molina Healthcare Passport |
$17.06
|
| Rate for Payer: Multiplan PHCS |
$161.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.30
|
| Rate for Payer: UHCCP Medicaid |
$16.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.23
|
|
|
EVAC SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
HCPCS 11740
|
| Hospital Charge Code |
45000037
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$21.97 |
| Max. Negotiated Rate |
$162.24 |
| Rate for Payer: Aetna Commercial |
$130.13
|
| Rate for Payer: Anthem Medicaid |
$58.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cigna Commercial |
$140.27
|
| Rate for Payer: First Health Commercial |
$160.55
|
| Rate for Payer: Humana Commercial |
$143.65
|
| Rate for Payer: Humana KY Medicaid |
$58.12
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$58.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$59.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.72
|
| Rate for Payer: Ohio Health Group HMO |
$126.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.39
|
| Rate for Payer: PHCS Commercial |
$162.24
|
| Rate for Payer: United Healthcare All Payer |
$148.72
|
|
|
EVAC SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
HCPCS 11740
|
| Hospital Charge Code |
76100098
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.97 |
| Max. Negotiated Rate |
$258.24 |
| Rate for Payer: Aetna Commercial |
$207.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.82
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: First Health Commercial |
$255.55
|
| Rate for Payer: Humana Commercial |
$228.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$220.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$198.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$236.72
|
| Rate for Payer: Ohio Health Group HMO |
$201.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.39
|
| Rate for Payer: PHCS Commercial |
$258.24
|
| Rate for Payer: United Healthcare All Payer |
$236.72
|
|
