|
ARCOS STD COND CAL SZ D+0 60MM
|
Facility
|
IP
|
$40,302.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,090.75 |
| Max. Negotiated Rate |
$38,690.40 |
| Rate for Payer: Aetna Commercial |
$31,032.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,435.95
|
| Rate for Payer: Cash Price |
$20,151.25
|
| Rate for Payer: Cigna Commercial |
$33,451.07
|
| Rate for Payer: First Health Commercial |
$38,287.38
|
| Rate for Payer: Humana Commercial |
$34,257.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,048.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,743.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,090.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,466.20
|
| Rate for Payer: Ohio Health Group HMO |
$30,226.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35,063.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,808.72
|
| Rate for Payer: PHCS Commercial |
$38,690.40
|
| Rate for Payer: United Healthcare All Payer |
$35,466.20
|
|
|
ARCOS STD COND CAL SZ D+0 60MM
|
Facility
|
OP
|
$40,302.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,090.75 |
| Max. Negotiated Rate |
$38,690.40 |
| Rate for Payer: Aetna Commercial |
$31,032.92
|
| Rate for Payer: Anthem Medicaid |
$13,860.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,435.95
|
| Rate for Payer: Cash Price |
$20,151.25
|
| Rate for Payer: Cigna Commercial |
$33,451.07
|
| Rate for Payer: First Health Commercial |
$38,287.38
|
| Rate for Payer: Humana Commercial |
$34,257.12
|
| Rate for Payer: Humana KY Medicaid |
$13,860.03
|
| Rate for Payer: Kentucky WC Medicaid |
$14,001.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,048.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,743.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,090.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,138.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,466.20
|
| Rate for Payer: Ohio Health Group HMO |
$30,226.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35,063.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,808.72
|
| Rate for Payer: PHCS Commercial |
$38,690.40
|
| Rate for Payer: United Healthcare All Payer |
$35,466.20
|
|
|
ARCOS STD COND CAL SZE +0 60MM
|
Facility
|
IP
|
$40,302.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,090.75 |
| Max. Negotiated Rate |
$38,690.40 |
| Rate for Payer: Aetna Commercial |
$31,032.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,435.95
|
| Rate for Payer: Cash Price |
$20,151.25
|
| Rate for Payer: Cigna Commercial |
$33,451.07
|
| Rate for Payer: First Health Commercial |
$38,287.38
|
| Rate for Payer: Humana Commercial |
$34,257.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,048.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,743.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,090.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,466.20
|
| Rate for Payer: Ohio Health Group HMO |
$30,226.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35,063.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,808.72
|
| Rate for Payer: PHCS Commercial |
$38,690.40
|
| Rate for Payer: United Healthcare All Payer |
$35,466.20
|
|
|
ARCOS STD COND CAL SZE +0 60MM
|
Facility
|
OP
|
$40,302.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,090.75 |
| Max. Negotiated Rate |
$38,690.40 |
| Rate for Payer: Aetna Commercial |
$31,032.92
|
| Rate for Payer: Anthem Medicaid |
$13,860.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,435.95
|
| Rate for Payer: Cash Price |
$20,151.25
|
| Rate for Payer: Cigna Commercial |
$33,451.07
|
| Rate for Payer: First Health Commercial |
$38,287.38
|
| Rate for Payer: Humana Commercial |
$34,257.12
|
| Rate for Payer: Humana KY Medicaid |
$13,860.03
|
| Rate for Payer: Kentucky WC Medicaid |
$14,001.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,048.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,743.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,090.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,138.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,466.20
|
| Rate for Payer: Ohio Health Group HMO |
$30,226.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35,063.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,808.72
|
| Rate for Payer: PHCS Commercial |
$38,690.40
|
| Rate for Payer: United Healthcare All Payer |
$35,466.20
|
|
|
AREXVY 120mcg KIT
|
Facility
|
IP
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
770T0089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$252.60 |
| 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 |
$673.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$732.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.98
|
| 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 |
77000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$252.60 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Aetna Commercial |
$682.49
|
| Rate for Payer: Anthem Medicaid |
$289.56
|
| Rate for Payer: Anthem Medicaid |
$304.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.35
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cash Price |
$443.18
|
| Rate for Payer: Cigna Commercial |
$735.67
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: First Health Commercial |
$842.03
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Humana Commercial |
$753.40
|
| Rate for Payer: Humana KY Medicaid |
$289.56
|
| Rate for Payer: Humana KY Medicaid |
$304.82
|
| Rate for Payer: Kentucky WC Medicaid |
$307.92
|
| 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 |
$726.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$295.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$310.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$779.99
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group HMO |
$664.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$673.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$732.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$611.58
|
| Rate for Payer: PHCS Commercial |
$850.90
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: United Healthcare All Payer |
$779.99
|
| 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 |
$252.60 |
| 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 |
$673.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$732.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.98
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| 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 |
$274.40 |
| Max. Negotiated Rate |
$589.40 |
| Rate for Payer: Anthem Medicaid |
$274.40
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Humana Medicaid |
$274.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.89
|
| Rate for Payer: Molina Healthcare Passport |
$274.40
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$277.14
|
|
|
AREXVY 120mcg KIT
|
Facility
|
IP
|
$842.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
77000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$252.60 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Aetna Commercial |
$682.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.35
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cash Price |
$443.18
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: Cigna Commercial |
$735.67
|
| Rate for Payer: First Health Commercial |
$842.03
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$753.40
|
| 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 |
$726.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$779.99
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group HMO |
$664.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$673.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$732.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$611.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.98
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: PHCS Commercial |
$850.90
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
| Rate for Payer: United Healthcare All Payer |
$779.99
|
|
|
ARGATROBAN 5MG/5ML VIAL 50ML
|
Facility
|
IP
|
$548.45
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
25001992
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.53 |
| 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 |
$164.53
|
| 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 |
$438.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.43
|
| 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 |
$0.74 |
| 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 |
$0.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.00
|
| 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 |
$0.74
|
| 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 |
$0.89
|
| 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 |
$438.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.43
|
| Rate for Payer: PHCS Commercial |
$526.51
|
| Rate for Payer: United Healthcare All Payer |
$482.64
|
|
|
ARICEPT 23MG TABLET
|
Facility
|
OP
|
$9.82
|
|
|
Service Code
|
NDC 24979000407
|
| Hospital Charge Code |
25000249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| 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 |
$7.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.78
|
| Rate for Payer: PHCS Commercial |
$9.43
|
| Rate for Payer: United Healthcare All Payer |
$8.64
|
|
|
ARICEPT 23MG TABLET
|
Facility
|
IP
|
$9.82
|
|
|
Service Code
|
NDC 24979000407
|
| Hospital Charge Code |
25000249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| 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 |
$7.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.78
|
| Rate for Payer: PHCS Commercial |
$9.43
|
| Rate for Payer: United Healthcare All Payer |
$8.64
|
|
|
ARICEPT (DONEPEZIL) 10MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
25000247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
ARICEPT (DONEPEZIL) 10MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
25000247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$7.07 |
| 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 |
$18.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.27
|
| 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 |
$7.07 |
| 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 |
$18.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.27
|
| Rate for Payer: PHCS Commercial |
$22.64
|
| Rate for Payer: United Healthcare All Payer |
$20.75
|
|
|
AR II MOD 6F 100CM
|
Facility
|
OP
|
$168.75
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna Commercial |
$129.94
|
| Rate for Payer: Anthem Medicaid |
$58.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.62
|
| Rate for Payer: Cash Price |
$84.38
|
| Rate for Payer: Cigna Commercial |
$140.06
|
| Rate for Payer: First Health Commercial |
$160.31
|
| Rate for Payer: Humana Commercial |
$143.44
|
| Rate for Payer: Humana KY Medicaid |
$58.03
|
| Rate for Payer: Kentucky WC Medicaid |
$58.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$59.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.50
|
| Rate for Payer: Ohio Health Group HMO |
$126.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.44
|
| Rate for Payer: PHCS Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Payer |
$148.50
|
|
|
AR II MOD 6F 100CM
|
Facility
|
IP
|
$168.75
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna Commercial |
$129.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.62
|
| Rate for Payer: Cash Price |
$84.38
|
| Rate for Payer: Cigna Commercial |
$140.06
|
| Rate for Payer: First Health Commercial |
$160.31
|
| Rate for Payer: Humana Commercial |
$143.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.50
|
| Rate for Payer: Ohio Health Group HMO |
$126.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.44
|
| Rate for Payer: PHCS Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Payer |
$148.50
|
|
|
AR I MOD 6F 100CM
|
Facility
|
IP
|
$163.69
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.11 |
| Max. Negotiated Rate |
$157.14 |
| Rate for Payer: Aetna Commercial |
$126.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Cash Price |
$81.84
|
| Rate for Payer: Cigna Commercial |
$135.86
|
| Rate for Payer: First Health Commercial |
$155.51
|
| Rate for Payer: Humana Commercial |
$139.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.05
|
| Rate for Payer: Ohio Health Group HMO |
$122.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.95
|
| Rate for Payer: PHCS Commercial |
$157.14
|
| Rate for Payer: United Healthcare All Payer |
$144.05
|
|
|
AR I MOD 6F 100CM
|
Facility
|
OP
|
$163.69
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.11 |
| Max. Negotiated Rate |
$157.14 |
| Rate for Payer: Aetna Commercial |
$126.04
|
| Rate for Payer: Anthem Medicaid |
$56.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Cash Price |
$81.84
|
| Rate for Payer: Cigna Commercial |
$135.86
|
| Rate for Payer: First Health Commercial |
$155.51
|
| Rate for Payer: Humana Commercial |
$139.14
|
| Rate for Payer: Humana KY Medicaid |
$56.29
|
| Rate for Payer: Kentucky WC Medicaid |
$56.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.05
|
| Rate for Payer: Ohio Health Group HMO |
$122.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.95
|
| Rate for Payer: PHCS Commercial |
$157.14
|
| Rate for Payer: United Healthcare All Payer |
$144.05
|
|
|
ARISTADA INITIO 675MG SYRINGE
|
Facility
|
IP
|
$13,271.89
|
|
|
Service Code
|
HCPCS J1943
|
| Hospital Charge Code |
25002845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,981.57 |
| Max. Negotiated Rate |
$12,741.01 |
| Rate for Payer: Aetna Commercial |
$10,219.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,352.07
|
| Rate for Payer: Cash Price |
$6,635.94
|
| Rate for Payer: Cigna Commercial |
$11,015.67
|
| Rate for Payer: First Health Commercial |
$12,608.30
|
| Rate for Payer: Humana Commercial |
$11,281.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,882.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,794.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,981.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,679.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,953.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,617.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,546.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,157.60
|
| Rate for Payer: PHCS Commercial |
$12,741.01
|
| Rate for Payer: United Healthcare All Payer |
$11,679.26
|
|
|
ARISTADA INITIO 675MG SYRINGE
|
Facility
|
OP
|
$13,271.89
|
|
|
Service Code
|
HCPCS J1943
|
| Hospital Charge Code |
25002845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$12,741.01 |
| Rate for Payer: Aetna Commercial |
$10,219.36
|
| Rate for Payer: Anthem Medicaid |
$4,564.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,352.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.40
|
| Rate for Payer: Cash Price |
$6,635.94
|
| Rate for Payer: Cash Price |
$6,635.94
|
| Rate for Payer: Cigna Commercial |
$11,015.67
|
| Rate for Payer: First Health Commercial |
$12,608.30
|
| Rate for Payer: Humana Commercial |
$11,281.11
|
| Rate for Payer: Humana KY Medicaid |
$4,564.20
|
| Rate for Payer: Humana Medicare Advantage |
$3.26
|
| Rate for Payer: Kentucky WC Medicaid |
$4,610.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,882.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,794.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,655.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,679.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,953.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,617.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,546.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,157.60
|
| Rate for Payer: PHCS Commercial |
$12,741.01
|
| Rate for Payer: United Healthcare All Payer |
$11,679.26
|
|
