|
ARCOS STD COND CAL SZ D+0 60MM
|
Facility
|
OP
|
$39,161.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,090.94 |
| Max. Negotiated Rate |
$37,594.66 |
| Rate for Payer: Aetna Commercial |
$30,154.05
|
| Rate for Payer: Anthem Medicaid |
$13,467.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,545.66
|
| Rate for Payer: Cash Price |
$19,580.55
|
| Rate for Payer: Cigna Commercial |
$32,503.71
|
| Rate for Payer: First Health Commercial |
$37,203.04
|
| Rate for Payer: Humana Commercial |
$33,286.94
|
| Rate for Payer: Humana KY Medicaid |
$13,467.50
|
| Rate for Payer: Kentucky WC Medicaid |
$13,604.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,112.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,900.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,748.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,737.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,461.77
|
| Rate for Payer: Ohio Health Group HMO |
$29,370.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,832.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,090.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,139.94
|
| Rate for Payer: PHCS Commercial |
$37,594.66
|
| Rate for Payer: United Healthcare All Payer |
$34,461.77
|
|
|
ARCOS STD COND CAL SZ D+0 60MM
|
Facility
|
IP
|
$39,161.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,090.94 |
| Max. Negotiated Rate |
$37,594.66 |
| Rate for Payer: Aetna Commercial |
$30,154.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,545.66
|
| Rate for Payer: Cash Price |
$19,580.55
|
| Rate for Payer: Cigna Commercial |
$32,503.71
|
| Rate for Payer: First Health Commercial |
$37,203.04
|
| Rate for Payer: Humana Commercial |
$33,286.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,112.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,900.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,748.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,461.77
|
| Rate for Payer: Ohio Health Group HMO |
$29,370.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,832.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,090.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,139.94
|
| Rate for Payer: PHCS Commercial |
$37,594.66
|
| Rate for Payer: United Healthcare All Payer |
$34,461.77
|
|
|
ARCOS STD COND CAL SZE +0 60MM
|
Facility
|
OP
|
$39,161.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,090.94 |
| Max. Negotiated Rate |
$37,594.66 |
| Rate for Payer: Aetna Commercial |
$30,154.05
|
| Rate for Payer: Anthem Medicaid |
$13,467.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,545.66
|
| Rate for Payer: Cash Price |
$19,580.55
|
| Rate for Payer: Cigna Commercial |
$32,503.71
|
| Rate for Payer: First Health Commercial |
$37,203.04
|
| Rate for Payer: Humana Commercial |
$33,286.94
|
| Rate for Payer: Humana KY Medicaid |
$13,467.50
|
| Rate for Payer: Kentucky WC Medicaid |
$13,604.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,112.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,900.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,748.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,737.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,461.77
|
| Rate for Payer: Ohio Health Group HMO |
$29,370.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,832.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,090.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,139.94
|
| Rate for Payer: PHCS Commercial |
$37,594.66
|
| Rate for Payer: United Healthcare All Payer |
$34,461.77
|
|
|
ARCOS STD COND CAL SZE +0 60MM
|
Facility
|
IP
|
$39,161.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,090.94 |
| Max. Negotiated Rate |
$37,594.66 |
| Rate for Payer: Aetna Commercial |
$30,154.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,545.66
|
| Rate for Payer: Cash Price |
$19,580.55
|
| Rate for Payer: Cigna Commercial |
$32,503.71
|
| Rate for Payer: First Health Commercial |
$37,203.04
|
| Rate for Payer: Humana Commercial |
$33,286.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,112.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,900.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,748.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,461.77
|
| Rate for Payer: Ohio Health Group HMO |
$29,370.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,832.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,090.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,139.94
|
| Rate for Payer: PHCS Commercial |
$37,594.66
|
| Rate for Payer: United Healthcare All Payer |
$34,461.77
|
|
|
AREXVY 120mcg KIT
|
Facility
|
OP
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
77000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.46 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Anthem Medicaid |
$289.56
|
| Rate for Payer: Anthem Medicaid |
$300.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$681.72
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cigna Commercial |
$725.42
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: First Health Commercial |
$830.30
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Humana Commercial |
$742.90
|
| Rate for Payer: Humana KY Medicaid |
$289.56
|
| Rate for Payer: Humana KY Medicaid |
$300.57
|
| Rate for Payer: Kentucky WC Medicaid |
$303.63
|
| Rate for Payer: Kentucky WC Medicaid |
$292.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$690.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$716.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$295.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$306.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$769.12
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group HMO |
$655.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$174.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$113.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$270.94
|
| Rate for Payer: PHCS Commercial |
$839.04
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: United Healthcare All Payer |
$769.12
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
|
|
AREXVY 120mcg KIT
|
Facility
|
IP
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
770T0089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.46 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$690.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.02
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
|
|
AREXVY 120mcg KIT
|
Facility
|
OP
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
770T0089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.46 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Anthem Medicaid |
$289.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Humana KY Medicaid |
$289.56
|
| Rate for Payer: Kentucky WC Medicaid |
$292.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$690.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$295.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.02
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
|
|
AREXVY 120mcg KIT
|
Facility
|
IP
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
77000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.46 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$681.72
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: Cigna Commercial |
$725.42
|
| Rate for Payer: First Health Commercial |
$830.30
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$742.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$690.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$716.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$769.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Group HMO |
$655.50
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$174.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$113.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$270.94
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: PHCS Commercial |
$839.04
|
| Rate for Payer: United Healthcare All Payer |
$769.12
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
|
|
AREXVY 120mcg KIT
|
Professional
|
Both
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
77000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.70 |
| Max. Negotiated Rate |
$842.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$842.00
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Multiplan PHCS |
$505.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$589.40
|
| Rate for Payer: UHCCP Medicaid |
$294.70
|
|
|
ARGATROBAN 5MG/5ML VIAL 50ML
|
Facility
|
IP
|
$548.45
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
25001992
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.30 |
| Max. Negotiated Rate |
$526.51 |
| Rate for Payer: Aetna Commercial |
$422.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.79
|
| Rate for Payer: Cash Price |
$274.22
|
| Rate for Payer: Cigna Commercial |
$455.21
|
| Rate for Payer: First Health Commercial |
$521.03
|
| Rate for Payer: Humana Commercial |
$466.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.64
|
| Rate for Payer: Ohio Health Group HMO |
$411.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.02
|
| Rate for Payer: PHCS Commercial |
$526.51
|
| Rate for Payer: United Healthcare All Payer |
$482.64
|
|
|
ARGATROBAN 5MG/5ML VIAL 50ML
|
Facility
|
OP
|
$548.45
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
25001992
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$526.51 |
| Rate for Payer: Aetna Commercial |
$422.31
|
| Rate for Payer: Anthem Medicaid |
$188.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$274.22
|
| Rate for Payer: Cash Price |
$274.22
|
| Rate for Payer: Cigna Commercial |
$455.21
|
| Rate for Payer: First Health Commercial |
$521.03
|
| Rate for Payer: Humana Commercial |
$466.18
|
| Rate for Payer: Humana KY Medicaid |
$188.61
|
| Rate for Payer: Humana Medicare Advantage |
$1.22
|
| Rate for Payer: Kentucky WC Medicaid |
$190.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.64
|
| Rate for Payer: Ohio Health Group HMO |
$411.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.02
|
| Rate for Payer: PHCS Commercial |
$526.51
|
| Rate for Payer: United Healthcare All Payer |
$482.64
|
|
|
ARICEPT 23MG TABLET
|
Facility
|
IP
|
$9.82
|
|
|
Service Code
|
NDC 24979000407
|
| Hospital Charge Code |
25000249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.43 |
| Rate for Payer: Aetna Commercial |
$7.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.66
|
| Rate for Payer: Cash Price |
$4.91
|
| Rate for Payer: Cigna Commercial |
$8.15
|
| Rate for Payer: First Health Commercial |
$9.33
|
| Rate for Payer: Humana Commercial |
$8.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.64
|
| Rate for Payer: Ohio Health Group HMO |
$7.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$9.43
|
| Rate for Payer: United Healthcare All Payer |
$8.64
|
|
|
ARICEPT 23MG TABLET
|
Facility
|
OP
|
$9.82
|
|
|
Service Code
|
NDC 24979000407
|
| Hospital Charge Code |
25000249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.43 |
| Rate for Payer: Aetna Commercial |
$7.56
|
| Rate for Payer: Anthem Medicaid |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.66
|
| Rate for Payer: Cash Price |
$4.91
|
| Rate for Payer: Cigna Commercial |
$8.15
|
| Rate for Payer: First Health Commercial |
$9.33
|
| Rate for Payer: Humana Commercial |
$8.35
|
| Rate for Payer: Humana KY Medicaid |
$3.38
|
| Rate for Payer: Kentucky WC Medicaid |
$3.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.64
|
| Rate for Payer: Ohio Health Group HMO |
$7.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$9.43
|
| Rate for Payer: United Healthcare All Payer |
$8.64
|
|
|
ARICEPT (DONEPEZIL) 10MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
25000247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
ARICEPT (DONEPEZIL) 10MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
25000247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
ARICEPT (DONEPEZIL) 5MG 1/TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
25000248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
ARICEPT (DONEPEZIL) 5MG 1/TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
25000248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
ARIDOL BRONCHIAL CHALLENGE KIT
|
Facility
|
OP
|
$23.58
|
|
|
Service Code
|
HCPCS J7665
|
| Hospital Charge Code |
25002518
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$22.64 |
| Rate for Payer: Aetna Commercial |
$18.16
|
| Rate for Payer: Anthem Medicaid |
$8.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.39
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: Cigna Commercial |
$19.57
|
| Rate for Payer: First Health Commercial |
$22.40
|
| Rate for Payer: Humana Commercial |
$20.04
|
| Rate for Payer: Humana KY Medicaid |
$8.11
|
| Rate for Payer: Kentucky WC Medicaid |
$8.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.75
|
| Rate for Payer: Ohio Health Group HMO |
$17.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.31
|
| Rate for Payer: PHCS Commercial |
$22.64
|
| Rate for Payer: United Healthcare All Payer |
$20.75
|
|
|
ARIDOL BRONCHIAL CHALLENGE KIT
|
Facility
|
IP
|
$23.58
|
|
|
Service Code
|
HCPCS J7665
|
| Hospital Charge Code |
25002518
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$22.64 |
| Rate for Payer: Aetna Commercial |
$18.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.39
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: Cigna Commercial |
$19.57
|
| Rate for Payer: First Health Commercial |
$22.40
|
| Rate for Payer: Humana Commercial |
$20.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.75
|
| Rate for Payer: Ohio Health Group HMO |
$17.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.31
|
| Rate for Payer: PHCS Commercial |
$22.64
|
| Rate for Payer: United Healthcare All Payer |
$20.75
|
|
|
AR II MOD 6F 100CM
|
Facility
|
IP
|
$164.70
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Aetna Commercial |
$126.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.47
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cigna Commercial |
$136.70
|
| Rate for Payer: First Health Commercial |
$156.46
|
| Rate for Payer: Humana Commercial |
$140.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.94
|
| Rate for Payer: Ohio Health Group HMO |
$123.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.06
|
| Rate for Payer: PHCS Commercial |
$158.11
|
| Rate for Payer: United Healthcare All Payer |
$144.94
|
|
|
AR II MOD 6F 100CM
|
Facility
|
OP
|
$164.70
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Aetna Commercial |
$126.82
|
| Rate for Payer: Anthem Medicaid |
$56.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.47
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cigna Commercial |
$136.70
|
| Rate for Payer: First Health Commercial |
$156.46
|
| Rate for Payer: Humana Commercial |
$140.00
|
| Rate for Payer: Humana KY Medicaid |
$56.64
|
| Rate for Payer: Kentucky WC Medicaid |
$57.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.94
|
| Rate for Payer: Ohio Health Group HMO |
$123.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.06
|
| Rate for Payer: PHCS Commercial |
$158.11
|
| Rate for Payer: United Healthcare All Payer |
$144.94
|
|
|
AR I MOD 6F 100CM
|
Facility
|
OP
|
$159.98
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.58 |
| Rate for Payer: Aetna Commercial |
$123.18
|
| Rate for Payer: Anthem Medicaid |
$55.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.78
|
| Rate for Payer: Cash Price |
$79.99
|
| Rate for Payer: Cigna Commercial |
$132.78
|
| Rate for Payer: First Health Commercial |
$151.98
|
| Rate for Payer: Humana Commercial |
$135.98
|
| Rate for Payer: Humana KY Medicaid |
$55.02
|
| Rate for Payer: Kentucky WC Medicaid |
$55.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$56.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.78
|
| Rate for Payer: Ohio Health Group HMO |
$119.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.59
|
| Rate for Payer: PHCS Commercial |
$153.58
|
| Rate for Payer: United Healthcare All Payer |
$140.78
|
|
|
AR I MOD 6F 100CM
|
Facility
|
IP
|
$159.98
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.58 |
| Rate for Payer: Aetna Commercial |
$123.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.78
|
| Rate for Payer: Cash Price |
$79.99
|
| Rate for Payer: Cigna Commercial |
$132.78
|
| Rate for Payer: First Health Commercial |
$151.98
|
| Rate for Payer: Humana Commercial |
$135.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.78
|
| Rate for Payer: Ohio Health Group HMO |
$119.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.59
|
| Rate for Payer: PHCS Commercial |
$153.58
|
| Rate for Payer: United Healthcare All Payer |
$140.78
|
|
|
ARISTADA INITIO 675MG SYRINGE
|
Facility
|
IP
|
$12,885.33
|
|
|
Service Code
|
HCPCS J1943
|
| Hospital Charge Code |
25002845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,675.09 |
| Max. Negotiated Rate |
$12,369.92 |
| Rate for Payer: Aetna Commercial |
$9,921.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,050.56
|
| Rate for Payer: Cash Price |
$6,442.66
|
| Rate for Payer: Cigna Commercial |
$10,694.82
|
| Rate for Payer: First Health Commercial |
$12,241.06
|
| Rate for Payer: Humana Commercial |
$10,952.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,565.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,509.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,865.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,339.09
|
| Rate for Payer: Ohio Health Group HMO |
$9,664.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,577.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,675.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,994.45
|
| Rate for Payer: PHCS Commercial |
$12,369.92
|
| Rate for Payer: United Healthcare All Payer |
$11,339.09
|
|
|
ARISTADA INITIO 675MG SYRINGE
|
Facility
|
OP
|
$12,885.33
|
|
|
Service Code
|
HCPCS J1943
|
| Hospital Charge Code |
25002845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$12,369.92 |
| Rate for Payer: Aetna Commercial |
$9,921.70
|
| Rate for Payer: Anthem Medicaid |
$4,431.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,050.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.17
|
| Rate for Payer: Cash Price |
$6,442.66
|
| Rate for Payer: Cash Price |
$6,442.66
|
| Rate for Payer: Cigna Commercial |
$10,694.82
|
| Rate for Payer: First Health Commercial |
$12,241.06
|
| Rate for Payer: Humana Commercial |
$10,952.53
|
| Rate for Payer: Humana KY Medicaid |
$4,431.26
|
| Rate for Payer: Humana Medicare Advantage |
$3.09
|
| Rate for Payer: Kentucky WC Medicaid |
$4,476.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,565.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,509.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,520.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,339.09
|
| Rate for Payer: Ohio Health Group HMO |
$9,664.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,577.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,675.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,994.45
|
| Rate for Payer: PHCS Commercial |
$12,369.92
|
| Rate for Payer: United Healthcare All Payer |
$11,339.09
|
|
