|
ABDOMINOPLASTY - MINI
|
Professional
|
Both
|
$780.00
|
|
| Hospital Charge Code |
22200085
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$780.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$780.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Multiplan PHCS |
$468.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$546.00
|
| Rate for Payer: UHCCP Medicaid |
$273.00
|
|
|
ABDOMINOPLASTY-MINI -80
|
Professional
|
Both
|
$390.00
|
|
| Hospital Charge Code |
22200384
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$390.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$273.00
|
| Rate for Payer: UHCCP Medicaid |
$136.50
|
|
|
ABD ULTRASOUND COMPLETE
|
Facility
|
OP
|
$1,332.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
40200013
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,278.72 |
| Rate for Payer: Aetna Commercial |
$1,025.64
|
| Rate for Payer: Anthem Medicaid |
$458.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,038.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$666.00
|
| Rate for Payer: Cash Price |
$666.00
|
| Rate for Payer: Cigna Commercial |
$1,105.56
|
| Rate for Payer: First Health Commercial |
$1,265.40
|
| Rate for Payer: Humana Commercial |
$1,132.20
|
| Rate for Payer: Humana KY Medicaid |
$458.07
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$462.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,092.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$983.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$467.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,172.16
|
| Rate for Payer: Ohio Health Group HMO |
$999.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$266.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$412.92
|
| Rate for Payer: PHCS Commercial |
$1,278.72
|
| Rate for Payer: United Healthcare All Payer |
$1,172.16
|
|
|
ABD ULTRASOUND COMPLETE
|
Facility
|
IP
|
$1,332.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
40200013
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$173.16 |
| Max. Negotiated Rate |
$1,278.72 |
| Rate for Payer: Aetna Commercial |
$1,025.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,038.96
|
| Rate for Payer: Cash Price |
$666.00
|
| Rate for Payer: Cigna Commercial |
$1,105.56
|
| Rate for Payer: First Health Commercial |
$1,265.40
|
| Rate for Payer: Humana Commercial |
$1,132.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,092.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$983.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,172.16
|
| Rate for Payer: Ohio Health Group HMO |
$999.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$266.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$412.92
|
| Rate for Payer: PHCS Commercial |
$1,278.72
|
| Rate for Payer: United Healthcare All Payer |
$1,172.16
|
|
|
ABD ULTRASOUND COMPLETE
|
Professional
|
Both
|
$1,332.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
40200013
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$51.01 |
| Max. Negotiated Rate |
$1,332.00 |
| Rate for Payer: Aetna Commercial |
$207.83
|
| Rate for Payer: Anthem Medicaid |
$88.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,332.00
|
| Rate for Payer: Cash Price |
$666.00
|
| Rate for Payer: Cash Price |
$666.00
|
| Rate for Payer: Cigna Commercial |
$183.40
|
| Rate for Payer: Healthspan PPO |
$194.74
|
| Rate for Payer: Humana Medicaid |
$88.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.02
|
| Rate for Payer: Molina Healthcare Passport |
$88.25
|
| Rate for Payer: Multiplan PHCS |
$799.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$932.40
|
| Rate for Payer: UHCCP Medicaid |
$466.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.13
|
|
|
ABD ULTRASOUND COMPLETE(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
402P0013
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$51.01 |
| Max. Negotiated Rate |
$207.83 |
| Rate for Payer: Aetna Commercial |
$207.83
|
| Rate for Payer: Anthem Medicaid |
$88.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$183.40
|
| Rate for Payer: Healthspan PPO |
$194.74
|
| Rate for Payer: Humana Medicaid |
$88.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.02
|
| Rate for Payer: Molina Healthcare Passport |
$88.25
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.13
|
|
|
ABD ULTRASOUND COMPLETE(T
|
Facility
|
OP
|
$1,182.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
402T0013
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,134.72 |
| Rate for Payer: Aetna Commercial |
$910.14
|
| Rate for Payer: Anthem Medicaid |
$406.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$921.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$591.00
|
| Rate for Payer: Cash Price |
$591.00
|
| Rate for Payer: Cigna Commercial |
$981.06
|
| Rate for Payer: First Health Commercial |
$1,122.90
|
| Rate for Payer: Humana Commercial |
$1,004.70
|
| Rate for Payer: Humana KY Medicaid |
$406.49
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$410.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$969.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$872.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$414.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,040.16
|
| Rate for Payer: Ohio Health Group HMO |
$886.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.42
|
| Rate for Payer: PHCS Commercial |
$1,134.72
|
| Rate for Payer: United Healthcare All Payer |
$1,040.16
|
|
|
ABD ULTRASOUND COMPLETE(T
|
Facility
|
IP
|
$1,182.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
402T0013
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$153.66 |
| Max. Negotiated Rate |
$1,134.72 |
| Rate for Payer: Aetna Commercial |
$910.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$921.96
|
| Rate for Payer: Cash Price |
$591.00
|
| Rate for Payer: Cigna Commercial |
$981.06
|
| Rate for Payer: First Health Commercial |
$1,122.90
|
| Rate for Payer: Humana Commercial |
$1,004.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$969.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$872.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$354.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,040.16
|
| Rate for Payer: Ohio Health Group HMO |
$886.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.42
|
| Rate for Payer: PHCS Commercial |
$1,134.72
|
| Rate for Payer: United Healthcare All Payer |
$1,040.16
|
|
|
ABELCET 10MG
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
HCPCS J0287
|
| Hospital Charge Code |
25001859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$511.68 |
| Rate for Payer: Aetna Commercial |
$410.41
|
| Rate for Payer: Anthem Medicaid |
$183.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$415.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.03
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cigna Commercial |
$442.39
|
| Rate for Payer: First Health Commercial |
$506.35
|
| Rate for Payer: Humana Commercial |
$453.05
|
| Rate for Payer: Humana KY Medicaid |
$183.30
|
| Rate for Payer: Humana Medicare Advantage |
$11.13
|
| Rate for Payer: Kentucky WC Medicaid |
$185.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.04
|
| Rate for Payer: Ohio Health Group HMO |
$399.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.23
|
| Rate for Payer: PHCS Commercial |
$511.68
|
| Rate for Payer: United Healthcare All Payer |
$469.04
|
|
|
ABELCET 10MG
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
HCPCS J0287
|
| Hospital Charge Code |
25001859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.29 |
| Max. Negotiated Rate |
$511.68 |
| Rate for Payer: Aetna Commercial |
$410.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$415.74
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cigna Commercial |
$442.39
|
| Rate for Payer: First Health Commercial |
$506.35
|
| Rate for Payer: Humana Commercial |
$453.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.04
|
| Rate for Payer: Ohio Health Group HMO |
$399.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.23
|
| Rate for Payer: PHCS Commercial |
$511.68
|
| Rate for Payer: United Healthcare All Payer |
$469.04
|
|
|
ABILIFY 15 MG TABLET
|
Facility
|
IP
|
$36.46
|
|
|
Service Code
|
NDC 59148000913
|
| Hospital Charge Code |
25000130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.44
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cigna Commercial |
$30.26
|
| Rate for Payer: First Health Commercial |
$34.64
|
| Rate for Payer: Humana Commercial |
$30.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.08
|
| Rate for Payer: Ohio Health Group HMO |
$27.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.30
|
| Rate for Payer: PHCS Commercial |
$35.00
|
| Rate for Payer: United Healthcare All Payer |
$32.08
|
|
|
ABILIFY 15 MG TABLET
|
Facility
|
OP
|
$36.46
|
|
|
Service Code
|
NDC 59148000913
|
| Hospital Charge Code |
25000130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Anthem Medicaid |
$12.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.44
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cigna Commercial |
$30.26
|
| Rate for Payer: First Health Commercial |
$34.64
|
| Rate for Payer: Humana Commercial |
$30.99
|
| Rate for Payer: Humana KY Medicaid |
$12.54
|
| Rate for Payer: Kentucky WC Medicaid |
$12.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.08
|
| Rate for Payer: Ohio Health Group HMO |
$27.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.30
|
| Rate for Payer: PHCS Commercial |
$35.00
|
| Rate for Payer: United Healthcare All Payer |
$32.08
|
|
|
ABILIFY 20 MG TABLET
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 65162090109
|
| Hospital Charge Code |
25000131
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
ABILIFY 20 MG TABLET
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 65162090109
|
| Hospital Charge Code |
25000131
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
ABILIFY 2MG TABLET
|
Facility
|
IP
|
$9.04
|
|
|
Service Code
|
NDC 50268008712
|
| Hospital Charge Code |
25000132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Aetna Commercial |
$6.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.05
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cigna Commercial |
$7.50
|
| Rate for Payer: First Health Commercial |
$8.59
|
| Rate for Payer: Humana Commercial |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.80
|
| Rate for Payer: PHCS Commercial |
$8.68
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
ABILIFY 2MG TABLET
|
Facility
|
OP
|
$9.04
|
|
|
Service Code
|
NDC 50268008712
|
| Hospital Charge Code |
25000132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Aetna Commercial |
$6.96
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.05
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cigna Commercial |
$7.50
|
| Rate for Payer: First Health Commercial |
$8.59
|
| Rate for Payer: Humana Commercial |
$7.68
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.80
|
| Rate for Payer: PHCS Commercial |
$8.68
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
ABILIFY (ARIPIPRAZOLE) 10MGTAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 62332009930
|
| Hospital Charge Code |
25000128
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
ABILIFY (ARIPIPRAZOLE) 10MGTAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 62332009930
|
| Hospital Charge Code |
25000128
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
ABILIFY (ARIPIPRAZOLE) 5MG TAB
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 50268008815
|
| Hospital Charge Code |
25000129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.45
|
| Rate for Payer: Humana Commercial |
$3.98
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.84
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.12
|
| Rate for Payer: Ohio Health Group HMO |
$3.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
ABILIFY (ARIPIPRAZOLE) 5MG TAB
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 50268008815
|
| Hospital Charge Code |
25000129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.45
|
| Rate for Payer: Humana Commercial |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.12
|
| Rate for Payer: Ohio Health Group HMO |
$3.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
ABILIFY MAINTENA 1mg(300mgPFS)
|
Facility
|
IP
|
$35.69
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
636T0183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$34.26 |
| Rate for Payer: Aetna Commercial |
$27.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.84
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cigna Commercial |
$29.62
|
| Rate for Payer: First Health Commercial |
$33.91
|
| Rate for Payer: Humana Commercial |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.41
|
| Rate for Payer: Ohio Health Group HMO |
$26.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.06
|
| Rate for Payer: PHCS Commercial |
$34.26
|
| Rate for Payer: United Healthcare All Payer |
$31.41
|
|
|
ABILIFY MAINTENA 1mg(300mgPFS)
|
Facility
|
OP
|
$35.69
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$34.26 |
| Rate for Payer: Aetna Commercial |
$27.48
|
| Rate for Payer: Anthem Medicaid |
$12.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.19
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cigna Commercial |
$29.62
|
| Rate for Payer: First Health Commercial |
$33.91
|
| Rate for Payer: Humana Commercial |
$30.34
|
| Rate for Payer: Humana KY Medicaid |
$12.27
|
| Rate for Payer: Humana Medicare Advantage |
$6.81
|
| Rate for Payer: Kentucky WC Medicaid |
$12.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.41
|
| Rate for Payer: Ohio Health Group HMO |
$26.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.06
|
| Rate for Payer: PHCS Commercial |
$34.26
|
| Rate for Payer: United Healthcare All Payer |
$31.41
|
|
|
ABILIFY MAINTENA 1mg(300mgPFS)
|
Facility
|
OP
|
$11,526.10
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
25004353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.81 |
| Max. Negotiated Rate |
$11,065.06 |
| Rate for Payer: Aetna Commercial |
$8,875.10
|
| Rate for Payer: Anthem Medicaid |
$3,963.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,990.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.19
|
| Rate for Payer: Cash Price |
$5,763.05
|
| Rate for Payer: Cash Price |
$5,763.05
|
| Rate for Payer: Cigna Commercial |
$9,566.66
|
| Rate for Payer: First Health Commercial |
$10,949.80
|
| Rate for Payer: Humana Commercial |
$9,797.18
|
| Rate for Payer: Humana KY Medicaid |
$3,963.83
|
| Rate for Payer: Humana Medicare Advantage |
$6.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,004.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,451.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,506.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,043.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,142.97
|
| Rate for Payer: Ohio Health Group HMO |
$8,644.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,305.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,498.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,573.09
|
| Rate for Payer: PHCS Commercial |
$11,065.06
|
| Rate for Payer: United Healthcare All Payer |
$10,142.97
|
|
|
ABILIFY MAINTENA 1mg(300mgPFS)
|
Professional
|
Both
|
$35.69
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$35.69 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.69
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.08
|
| Rate for Payer: Multiplan PHCS |
$21.41
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.98
|
| Rate for Payer: UHCCP Medicaid |
$12.49
|
|
|
ABILIFY MAINTENA 1mg(300mgPFS)
|
Facility
|
OP
|
$35.69
|
|
|
Service Code
|
HCPCS J0401
|
| Hospital Charge Code |
636T0183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$34.26 |
| Rate for Payer: Aetna Commercial |
$27.48
|
| Rate for Payer: Anthem Medicaid |
$12.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.19
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cigna Commercial |
$29.62
|
| Rate for Payer: First Health Commercial |
$33.91
|
| Rate for Payer: Humana Commercial |
$30.34
|
| Rate for Payer: Humana KY Medicaid |
$12.27
|
| Rate for Payer: Humana Medicare Advantage |
$6.81
|
| Rate for Payer: Kentucky WC Medicaid |
$12.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.41
|
| Rate for Payer: Ohio Health Group HMO |
$26.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.06
|
| Rate for Payer: PHCS Commercial |
$34.26
|
| Rate for Payer: United Healthcare All Payer |
$31.41
|
|
