|
INTUITRAK AAA .035 GUIDEWIRE
|
Facility
|
OP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem Medicaid |
$662.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Humana KY Medicaid |
$662.87
|
| Rate for Payer: Kentucky WC Medicaid |
$669.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$676.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
INTUITRAK AAA .035 GUIDEWIRE
|
Facility
|
IP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
INTUSSUSCEPTION US
|
Professional
|
Both
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,104.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$662.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$772.80
|
| Rate for Payer: UHCCP Medicaid |
$386.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
INTUSSUSCEPTION US
|
Facility
|
IP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$143.52 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
INTUSSUSCEPTION US
|
Facility
|
OP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem Medicaid |
$379.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Humana KY Medicaid |
$379.67
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$383.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$387.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
INTUSSUSCEPTION US(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402P0017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$157.49 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
INTUSSUSCEPTION US(T
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$127.27 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
INTUSSUSCEPTION US(T
|
Facility
|
OP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem Medicaid |
$336.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Humana KY Medicaid |
$336.68
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$340.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
INVANZ 1GM/10ML VIAL
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
25003904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem Medicaid |
$74.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Humana KY Medicaid |
$74.97
|
| Rate for Payer: Kentucky WC Medicaid |
$75.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
INVANZ 1GM/10ML VIAL
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
25003904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
INVANZ 1GM/3.2ML IM
|
Facility
|
IP
|
$545.07
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
25003905
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.86 |
| Max. Negotiated Rate |
$523.27 |
| Rate for Payer: Aetna Commercial |
$419.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.15
|
| Rate for Payer: Cash Price |
$272.54
|
| Rate for Payer: Cigna Commercial |
$452.41
|
| Rate for Payer: First Health Commercial |
$517.82
|
| Rate for Payer: Humana Commercial |
$463.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.66
|
| Rate for Payer: Ohio Health Group HMO |
$408.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.97
|
| Rate for Payer: PHCS Commercial |
$523.27
|
| Rate for Payer: United Healthcare All Payer |
$479.66
|
|
|
INVANZ 1GM/3.2ML IM
|
Facility
|
OP
|
$545.07
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
25003905
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.86 |
| Max. Negotiated Rate |
$523.27 |
| Rate for Payer: Aetna Commercial |
$419.70
|
| Rate for Payer: Anthem Medicaid |
$187.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.15
|
| Rate for Payer: Cash Price |
$272.54
|
| Rate for Payer: Cigna Commercial |
$452.41
|
| Rate for Payer: First Health Commercial |
$517.82
|
| Rate for Payer: Humana Commercial |
$463.31
|
| Rate for Payer: Humana KY Medicaid |
$187.45
|
| Rate for Payer: Kentucky WC Medicaid |
$189.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.66
|
| Rate for Payer: Ohio Health Group HMO |
$408.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.97
|
| Rate for Payer: PHCS Commercial |
$523.27
|
| Rate for Payer: United Healthcare All Payer |
$479.66
|
|
|
INVANZ 500mg (1gm PreMix) ANE
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
25004145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem Medicaid |
$67.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Humana KY Medicaid |
$67.40
|
| Rate for Payer: Kentucky WC Medicaid |
$68.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.76
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
INVANZ 500mg (1gm PreMix) ANE
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
25004145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.76
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
INVEGA 3MG TABLET
|
Facility
|
IP
|
$10.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000788
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
INVEGA 3MG TABLET
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000788
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
INVEGA HAFYERA 1mg(1092mg Syr)
|
Facility
|
OP
|
$75,837.51
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
25004181
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$72,804.01 |
| Rate for Payer: Aetna Commercial |
$58,394.88
|
| Rate for Payer: Anthem Medicaid |
$26,080.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,153.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.48
|
| Rate for Payer: Cash Price |
$37,918.75
|
| Rate for Payer: Cash Price |
$37,918.75
|
| Rate for Payer: Cigna Commercial |
$62,945.13
|
| Rate for Payer: First Health Commercial |
$72,045.63
|
| Rate for Payer: Humana Commercial |
$64,461.88
|
| Rate for Payer: Humana KY Medicaid |
$26,080.52
|
| Rate for Payer: Humana Medicare Advantage |
$12.21
|
| Rate for Payer: Kentucky WC Medicaid |
$26,345.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,186.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,968.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,603.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,737.01
|
| Rate for Payer: Ohio Health Group HMO |
$56,878.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,167.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,858.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,509.63
|
| Rate for Payer: PHCS Commercial |
$72,804.01
|
| Rate for Payer: United Healthcare All Payer |
$66,737.01
|
|
|
INVEGA HAFYERA 1mg(1092mg Syr)
|
Facility
|
IP
|
$75,837.51
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
25004181
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,858.88 |
| Max. Negotiated Rate |
$72,804.01 |
| Rate for Payer: Aetna Commercial |
$58,394.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,153.26
|
| Rate for Payer: Cash Price |
$37,918.75
|
| Rate for Payer: Cigna Commercial |
$62,945.13
|
| Rate for Payer: First Health Commercial |
$72,045.63
|
| Rate for Payer: Humana Commercial |
$64,461.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,186.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,968.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,751.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,737.01
|
| Rate for Payer: Ohio Health Group HMO |
$56,878.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,167.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,858.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,509.63
|
| Rate for Payer: PHCS Commercial |
$72,804.01
|
| Rate for Payer: United Healthcare All Payer |
$66,737.01
|
|
|
INVEGA HAFYERA 1mg(1560mg Syr)
|
Facility
|
OP
|
$113,753.49
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
25004182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$109,203.35 |
| Rate for Payer: Aetna Commercial |
$87,590.19
|
| Rate for Payer: Anthem Medicaid |
$39,119.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88,727.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.48
|
| Rate for Payer: Cash Price |
$56,876.75
|
| Rate for Payer: Cash Price |
$56,876.75
|
| Rate for Payer: Cigna Commercial |
$94,415.40
|
| Rate for Payer: First Health Commercial |
$108,065.82
|
| Rate for Payer: Humana Commercial |
$96,690.47
|
| Rate for Payer: Humana KY Medicaid |
$39,119.83
|
| Rate for Payer: Humana Medicare Advantage |
$12.21
|
| Rate for Payer: Kentucky WC Medicaid |
$39,517.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93,277.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83,950.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$39,904.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$100,103.07
|
| Rate for Payer: Ohio Health Group HMO |
$85,315.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,750.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,787.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35,263.58
|
| Rate for Payer: PHCS Commercial |
$109,203.35
|
| Rate for Payer: United Healthcare All Payer |
$100,103.07
|
|
|
INVEGA HAFYERA 1mg(1560mg Syr)
|
Facility
|
IP
|
$113,753.49
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
25004182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,787.95 |
| Max. Negotiated Rate |
$109,203.35 |
| Rate for Payer: Aetna Commercial |
$87,590.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88,727.72
|
| Rate for Payer: Cash Price |
$56,876.75
|
| Rate for Payer: Cigna Commercial |
$94,415.40
|
| Rate for Payer: First Health Commercial |
$108,065.82
|
| Rate for Payer: Humana Commercial |
$96,690.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93,277.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83,950.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34,126.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$100,103.07
|
| Rate for Payer: Ohio Health Group HMO |
$85,315.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,750.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,787.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35,263.58
|
| Rate for Payer: PHCS Commercial |
$109,203.35
|
| Rate for Payer: United Healthcare All Payer |
$100,103.07
|
|
|
INVEGA SSTENNA 1MG (234MG)
|
Facility
|
OP
|
$18,958.92
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
25002289
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$18,200.56 |
| Rate for Payer: Aetna Commercial |
$14,598.37
|
| Rate for Payer: Anthem Medicaid |
$6,519.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,787.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.33
|
| Rate for Payer: Cash Price |
$9,479.46
|
| Rate for Payer: Cash Price |
$9,479.46
|
| Rate for Payer: Cigna Commercial |
$15,735.90
|
| Rate for Payer: First Health Commercial |
$18,010.97
|
| Rate for Payer: Humana Commercial |
$16,115.08
|
| Rate for Payer: Humana KY Medicaid |
$6,519.97
|
| Rate for Payer: Humana Medicare Advantage |
$14.32
|
| Rate for Payer: Kentucky WC Medicaid |
$6,586.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,546.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,991.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,650.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,683.85
|
| Rate for Payer: Ohio Health Group HMO |
$14,219.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,791.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,464.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,877.27
|
| Rate for Payer: PHCS Commercial |
$18,200.56
|
| Rate for Payer: United Healthcare All Payer |
$16,683.85
|
|
|
INVEGA SSTENNA 1MG (234MG)
|
Facility
|
IP
|
$18,958.92
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
25002289
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,464.66 |
| Max. Negotiated Rate |
$18,200.56 |
| Rate for Payer: Aetna Commercial |
$14,598.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,787.96
|
| Rate for Payer: Cash Price |
$9,479.46
|
| Rate for Payer: Cigna Commercial |
$15,735.90
|
| Rate for Payer: First Health Commercial |
$18,010.97
|
| Rate for Payer: Humana Commercial |
$16,115.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,546.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,991.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,687.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,683.85
|
| Rate for Payer: Ohio Health Group HMO |
$14,219.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,791.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,464.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,877.27
|
| Rate for Payer: PHCS Commercial |
$18,200.56
|
| Rate for Payer: United Healthcare All Payer |
$16,683.85
|
|
|
INVEGA SSTENNA 1MG (234MG)
|
Facility
|
IP
|
$69.52
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
63600048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$66.74 |
| Rate for Payer: Aetna Commercial |
$53.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.23
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Cigna Commercial |
$57.70
|
| Rate for Payer: First Health Commercial |
$66.04
|
| Rate for Payer: Humana Commercial |
$59.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.18
|
| Rate for Payer: Ohio Health Group HMO |
$52.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.55
|
| Rate for Payer: PHCS Commercial |
$66.74
|
| Rate for Payer: United Healthcare All Payer |
$61.18
|
|
|
INVEGA SSTENNA 1MG (234MG)
|
Facility
|
IP
|
$69.52
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
636T0048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$66.74 |
| Rate for Payer: Aetna Commercial |
$53.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.23
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Cigna Commercial |
$57.70
|
| Rate for Payer: First Health Commercial |
$66.04
|
| Rate for Payer: Humana Commercial |
$59.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.18
|
| Rate for Payer: Ohio Health Group HMO |
$52.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.55
|
| Rate for Payer: PHCS Commercial |
$66.74
|
| Rate for Payer: United Healthcare All Payer |
$61.18
|
|
|
INVEGA SSTENNA 1MG (234MG)
|
Professional
|
Both
|
$69.52
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
63600048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$69.52 |
| Rate for Payer: Aetna Commercial |
$17.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$69.52
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$17.16
|
| Rate for Payer: Multiplan PHCS |
$41.71
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$48.66
|
| Rate for Payer: UHCCP Medicaid |
$24.33
|
|
