|
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 |
$155.42 |
| 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 |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$704.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| 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 |
$155.42
|
| 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 |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$316.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$794.97
|
| Rate for Payer: Ohio Health Group HMO |
$677.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$785.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$623.33
|
| Rate for Payer: PHCS Commercial |
$867.24
|
| Rate for Payer: United Healthcare All Payer |
$794.97
|
|
|
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 |
$155.42 |
| Max. Negotiated Rate |
$542.03 |
| Rate for Payer: Aetna Commercial |
$190.26
|
| Rate for Payer: Ambetter Exchange |
$155.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$155.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$155.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.42
|
| Rate for Payer: Multiplan PHCS |
$542.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$202.05
|
| Rate for Payer: UHCCP Medicaid |
$316.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$155.42
|
|
|
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 |
$271.01 |
| 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 |
$677.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$785.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$623.33
|
| 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
|
$903.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.01 |
| 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 |
$677.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$785.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$623.33
|
| 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 |
$0.91 |
| 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 |
$2.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.08
|
| Rate for Payer: PHCS Commercial |
$2.90
|
| Rate for Payer: United Healthcare All Payer |
$2.66
|
|
|
ELIMITE(PERMETHRIN)5%CREAM60GM
|
Facility
|
OP
|
$3.02
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
25000611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| 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 |
$2.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.08
|
| Rate for Payer: PHCS Commercial |
$2.90
|
| Rate for Payer: United Healthcare All Payer |
$2.66
|
|
|
ELIQUIS 2.5MG TABLET
|
Facility
|
IP
|
$27.11
|
|
|
Service Code
|
NDC 3089331
|
| Hospital Charge Code |
25000612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$26.03 |
| Rate for Payer: Aetna Commercial |
$20.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna Commercial |
$22.50
|
| Rate for Payer: First Health Commercial |
$25.75
|
| Rate for Payer: Humana Commercial |
$23.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.86
|
| Rate for Payer: Ohio Health Group HMO |
$20.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$26.03
|
| Rate for Payer: United Healthcare All Payer |
$23.86
|
|
|
ELIQUIS 2.5MG TABLET
|
Facility
|
OP
|
$27.11
|
|
|
Service Code
|
NDC 3089331
|
| Hospital Charge Code |
25000612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$26.03 |
| Rate for Payer: Aetna Commercial |
$20.87
|
| Rate for Payer: Anthem Medicaid |
$9.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna Commercial |
$22.50
|
| Rate for Payer: First Health Commercial |
$25.75
|
| Rate for Payer: Humana Commercial |
$23.04
|
| Rate for Payer: Humana KY Medicaid |
$9.32
|
| Rate for Payer: Kentucky WC Medicaid |
$9.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.86
|
| Rate for Payer: Ohio Health Group HMO |
$20.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$26.03
|
| Rate for Payer: United Healthcare All Payer |
$23.86
|
|
|
ELIQUIS 5MG TABLET
|
Facility
|
IP
|
$27.11
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
25000613
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$26.03 |
| Rate for Payer: Aetna Commercial |
$20.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna Commercial |
$22.50
|
| Rate for Payer: First Health Commercial |
$25.75
|
| Rate for Payer: Humana Commercial |
$23.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.86
|
| Rate for Payer: Ohio Health Group HMO |
$20.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$26.03
|
| Rate for Payer: United Healthcare All Payer |
$23.86
|
|
|
ELIQUIS 5MG TABLET
|
Facility
|
OP
|
$27.11
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
25000613
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$26.03 |
| Rate for Payer: Aetna Commercial |
$20.87
|
| Rate for Payer: Anthem Medicaid |
$9.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna Commercial |
$22.50
|
| Rate for Payer: First Health Commercial |
$25.75
|
| Rate for Payer: Humana Commercial |
$23.04
|
| Rate for Payer: Humana KY Medicaid |
$9.32
|
| Rate for Payer: Kentucky WC Medicaid |
$9.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.86
|
| Rate for Payer: Ohio Health Group HMO |
$20.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$26.03
|
| Rate for Payer: United Healthcare All Payer |
$23.86
|
|
|
ELITEK 1.5 MG VL (0.5 MG JCODE
|
Facility
|
IP
|
$2,840.63
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$852.19 |
| Max. Negotiated Rate |
$2,727.00 |
| Rate for Payer: Aetna Commercial |
$2,187.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,215.69
|
| Rate for Payer: Cash Price |
$1,420.32
|
| Rate for Payer: Cigna Commercial |
$2,357.72
|
| Rate for Payer: First Health Commercial |
$2,698.60
|
| Rate for Payer: Humana Commercial |
$2,414.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,329.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,096.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$852.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,499.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,130.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,272.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,471.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,960.03
|
| Rate for Payer: PHCS Commercial |
$2,727.00
|
| Rate for Payer: United Healthcare All Payer |
$2,499.75
|
|
|
ELITEK 1.5 MG VL (0.5 MG JCODE
|
Facility
|
OP
|
$2,840.63
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.48 |
| Max. Negotiated Rate |
$2,727.00 |
| Rate for Payer: Aetna Commercial |
$2,187.29
|
| Rate for Payer: Anthem Medicaid |
$976.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$376.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,215.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$527.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$508.25
|
| Rate for Payer: Cash Price |
$1,420.32
|
| Rate for Payer: Cash Price |
$1,420.32
|
| Rate for Payer: Cigna Commercial |
$2,357.72
|
| Rate for Payer: First Health Commercial |
$2,698.60
|
| Rate for Payer: Humana Commercial |
$2,414.54
|
| Rate for Payer: Humana KY Medicaid |
$976.89
|
| Rate for Payer: Humana Medicare Advantage |
$376.48
|
| Rate for Payer: Kentucky WC Medicaid |
$986.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,329.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,096.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$996.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,499.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,130.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,272.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,471.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,960.03
|
| Rate for Payer: PHCS Commercial |
$2,727.00
|
| Rate for Payer: United Healthcare All Payer |
$2,499.75
|
|
|
ELITEK 7.5MG VL (0.5MG J CODE)
|
Facility
|
OP
|
$7,203.16
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.48 |
| Max. Negotiated Rate |
$6,915.03 |
| Rate for Payer: Aetna Commercial |
$5,546.43
|
| Rate for Payer: Anthem Medicaid |
$2,477.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$376.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,618.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$527.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$508.25
|
| Rate for Payer: Cash Price |
$3,601.58
|
| Rate for Payer: Cash Price |
$3,601.58
|
| Rate for Payer: Cigna Commercial |
$5,978.62
|
| Rate for Payer: First Health Commercial |
$6,843.00
|
| Rate for Payer: Humana Commercial |
$6,122.69
|
| Rate for Payer: Humana KY Medicaid |
$2,477.17
|
| Rate for Payer: Humana Medicare Advantage |
$376.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,502.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,906.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,315.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,526.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,338.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,402.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,762.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,266.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,970.18
|
| Rate for Payer: PHCS Commercial |
$6,915.03
|
| Rate for Payer: United Healthcare All Payer |
$6,338.78
|
|
|
ELITEK 7.5MG VL (0.5MG J CODE)
|
Facility
|
IP
|
$7,203.16
|
|
|
Service Code
|
HCPCS J2783
|
| Hospital Charge Code |
25002339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,160.95 |
| Max. Negotiated Rate |
$6,915.03 |
| Rate for Payer: Aetna Commercial |
$5,546.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,618.46
|
| Rate for Payer: Cash Price |
$3,601.58
|
| Rate for Payer: Cigna Commercial |
$5,978.62
|
| Rate for Payer: First Health Commercial |
$6,843.00
|
| Rate for Payer: Humana Commercial |
$6,122.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,906.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,315.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,160.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,338.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,402.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,762.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,266.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,970.18
|
| Rate for Payer: PHCS Commercial |
$6,915.03
|
| Rate for Payer: United Healthcare All Payer |
$6,338.78
|
|
|
ELMIRON(PENTPOLYSULF)100MG CAP
|
Facility
|
OP
|
$28.98
|
|
|
Service Code
|
NDC 50458009801
|
| Hospital Charge Code |
25000614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$27.82 |
| Rate for Payer: Aetna Commercial |
$22.31
|
| Rate for Payer: Anthem Medicaid |
$9.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.60
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna Commercial |
$24.05
|
| Rate for Payer: First Health Commercial |
$27.53
|
| Rate for Payer: Humana Commercial |
$24.63
|
| Rate for Payer: Humana KY Medicaid |
$9.97
|
| Rate for Payer: Kentucky WC Medicaid |
$10.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.50
|
| Rate for Payer: Ohio Health Group HMO |
$21.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.00
|
| Rate for Payer: PHCS Commercial |
$27.82
|
| Rate for Payer: United Healthcare All Payer |
$25.50
|
|
|
ELMIRON(PENTPOLYSULF)100MG CAP
|
Facility
|
IP
|
$28.98
|
|
|
Service Code
|
NDC 50458009801
|
| Hospital Charge Code |
25000614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$27.82 |
| Rate for Payer: Aetna Commercial |
$22.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.60
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna Commercial |
$24.05
|
| Rate for Payer: First Health Commercial |
$27.53
|
| Rate for Payer: Humana Commercial |
$24.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.50
|
| Rate for Payer: Ohio Health Group HMO |
$21.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.00
|
| Rate for Payer: PHCS Commercial |
$27.82
|
| Rate for Payer: United Healthcare All Payer |
$25.50
|
|
|
ELM TREE IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000939
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
ELM TREE IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000939
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
ELOCON (MOMETSONE) FURDAT 15GM
|
Facility
|
IP
|
$6.17
|
|
|
Service Code
|
NDC 713063415
|
| Hospital Charge Code |
25000615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| 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 |
$4.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.26
|
| Rate for Payer: PHCS Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Payer |
$5.43
|
|
|
ELOCON (MOMETSONE) FURDAT 15GM
|
Facility
|
OP
|
$6.17
|
|
|
Service Code
|
NDC 713063415
|
| Hospital Charge Code |
25000615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| 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 |
$4.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.26
|
| Rate for Payer: PHCS Commercial |
$5.92
|
| Rate for Payer: United Healthcare All Payer |
$5.43
|
|
|
ELOTUZUMAB 1mg (300mg SDV)
|
Facility
|
OP
|
$12,402.35
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$11,906.26 |
| Rate for Payer: Aetna Commercial |
$9,549.81
|
| Rate for Payer: Anthem Medicaid |
$4,265.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,673.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.64
|
| Rate for Payer: Cash Price |
$6,201.18
|
| Rate for Payer: Cash Price |
$6,201.18
|
| Rate for Payer: Cigna Commercial |
$10,293.95
|
| Rate for Payer: First Health Commercial |
$11,782.23
|
| Rate for Payer: Humana Commercial |
$10,542.00
|
| Rate for Payer: Humana KY Medicaid |
$4,265.17
|
| Rate for Payer: Humana Medicare Advantage |
$7.88
|
| Rate for Payer: Kentucky WC Medicaid |
$4,308.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,169.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,152.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,350.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,914.07
|
| Rate for Payer: Ohio Health Group HMO |
$9,301.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,921.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,790.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,557.62
|
| Rate for Payer: PHCS Commercial |
$11,906.26
|
| Rate for Payer: United Healthcare All Payer |
$10,914.07
|
|
|
ELOTUZUMAB 1mg (300mg SDV)
|
Facility
|
IP
|
$12,402.35
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,720.70 |
| Max. Negotiated Rate |
$11,906.26 |
| Rate for Payer: Aetna Commercial |
$9,549.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,673.83
|
| Rate for Payer: Cash Price |
$6,201.18
|
| Rate for Payer: Cigna Commercial |
$10,293.95
|
| Rate for Payer: First Health Commercial |
$11,782.23
|
| Rate for Payer: Humana Commercial |
$10,542.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,169.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,152.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,720.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,914.07
|
| Rate for Payer: Ohio Health Group HMO |
$9,301.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,921.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,790.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,557.62
|
| Rate for Payer: PHCS Commercial |
$11,906.26
|
| Rate for Payer: United Healthcare All Payer |
$10,914.07
|
|
|
ELOTUZUMAB 1mg (400mg SDV)
|
Facility
|
IP
|
$16,536.28
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,960.88 |
| Max. Negotiated Rate |
$15,874.83 |
| Rate for Payer: Aetna Commercial |
$12,732.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,898.30
|
| Rate for Payer: Cash Price |
$8,268.14
|
| Rate for Payer: Cigna Commercial |
$13,725.11
|
| Rate for Payer: First Health Commercial |
$15,709.47
|
| Rate for Payer: Humana Commercial |
$14,055.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,559.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,203.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,960.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,551.93
|
| Rate for Payer: Ohio Health Group HMO |
$12,402.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,229.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,386.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,410.03
|
| Rate for Payer: PHCS Commercial |
$15,874.83
|
| Rate for Payer: United Healthcare All Payer |
$14,551.93
|
|
|
ELOTUZUMAB 1mg (400mg SDV)
|
Facility
|
OP
|
$16,536.28
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
25004316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$15,874.83 |
| Rate for Payer: Aetna Commercial |
$12,732.94
|
| Rate for Payer: Anthem Medicaid |
$5,686.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,898.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.64
|
| Rate for Payer: Cash Price |
$8,268.14
|
| Rate for Payer: Cash Price |
$8,268.14
|
| Rate for Payer: Cigna Commercial |
$13,725.11
|
| Rate for Payer: First Health Commercial |
$15,709.47
|
| Rate for Payer: Humana Commercial |
$14,055.84
|
| Rate for Payer: Humana KY Medicaid |
$5,686.83
|
| Rate for Payer: Humana Medicare Advantage |
$7.88
|
| Rate for Payer: Kentucky WC Medicaid |
$5,744.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,559.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,203.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,800.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,551.93
|
| Rate for Payer: Ohio Health Group HMO |
$12,402.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,229.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,386.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,410.03
|
| Rate for Payer: PHCS Commercial |
$15,874.83
|
| Rate for Payer: United Healthcare All Payer |
$14,551.93
|
|
|
ELOXATIN 0.5MG 100MGVIAL
|
Facility
|
OP
|
$545.00
|
|
|
Service Code
|
HCPCS J9263
|
| Hospital Charge Code |
25002649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.50 |
| 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 |
$436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$474.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.05
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
