|
ARISTADA PER MG (1064MG SYR)
|
Facility
|
IP
|
$20,920.42
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,276.13 |
| Max. Negotiated Rate |
$20,083.60 |
| Rate for Payer: Aetna Commercial |
$16,108.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,317.93
|
| Rate for Payer: Cash Price |
$10,460.21
|
| Rate for Payer: Cigna Commercial |
$17,363.95
|
| Rate for Payer: First Health Commercial |
$19,874.40
|
| Rate for Payer: Humana Commercial |
$17,782.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,154.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,439.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,276.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,409.97
|
| Rate for Payer: Ohio Health Group HMO |
$15,690.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,736.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,200.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,435.09
|
| Rate for Payer: PHCS Commercial |
$20,083.60
|
| Rate for Payer: United Healthcare All Payer |
$18,409.97
|
|
|
ARISTADA PER MG (1064MG SYR)
|
Facility
|
OP
|
$20,920.42
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$20,083.60 |
| Rate for Payer: Aetna Commercial |
$16,108.72
|
| Rate for Payer: Anthem Medicaid |
$7,194.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,317.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$10,460.21
|
| Rate for Payer: Cash Price |
$10,460.21
|
| Rate for Payer: Cigna Commercial |
$17,363.95
|
| Rate for Payer: First Health Commercial |
$19,874.40
|
| Rate for Payer: Humana Commercial |
$17,782.36
|
| Rate for Payer: Humana KY Medicaid |
$7,194.53
|
| Rate for Payer: Humana Medicare Advantage |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$7,267.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,154.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,439.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,338.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,409.97
|
| Rate for Payer: Ohio Health Group HMO |
$15,690.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,736.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,200.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,435.09
|
| Rate for Payer: PHCS Commercial |
$20,083.60
|
| Rate for Payer: United Healthcare All Payer |
$18,409.97
|
|
|
ARISTADA PER MG (441MG SYR)
|
Facility
|
OP
|
$8,670.95
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$8,324.11 |
| Rate for Payer: Aetna Commercial |
$6,676.63
|
| Rate for Payer: Anthem Medicaid |
$2,981.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,763.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$4,335.48
|
| Rate for Payer: Cash Price |
$4,335.48
|
| Rate for Payer: Cigna Commercial |
$7,196.89
|
| Rate for Payer: First Health Commercial |
$8,237.40
|
| Rate for Payer: Humana Commercial |
$7,370.31
|
| Rate for Payer: Humana KY Medicaid |
$2,981.94
|
| Rate for Payer: Humana Medicare Advantage |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3,012.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,110.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,399.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,041.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,630.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,503.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,936.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,543.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,982.96
|
| Rate for Payer: PHCS Commercial |
$8,324.11
|
| Rate for Payer: United Healthcare All Payer |
$7,630.44
|
|
|
ARISTADA PER MG (441MG SYR)
|
Facility
|
IP
|
$8,670.95
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,601.28 |
| Max. Negotiated Rate |
$8,324.11 |
| Rate for Payer: Aetna Commercial |
$6,676.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,763.34
|
| Rate for Payer: Cash Price |
$4,335.48
|
| Rate for Payer: Cigna Commercial |
$7,196.89
|
| Rate for Payer: First Health Commercial |
$8,237.40
|
| Rate for Payer: Humana Commercial |
$7,370.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,110.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,399.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,601.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,630.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,503.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,936.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,543.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,982.96
|
| Rate for Payer: PHCS Commercial |
$8,324.11
|
| Rate for Payer: United Healthcare All Payer |
$7,630.44
|
|
|
ARISTADA PER MG (662MG SYR)
|
Facility
|
OP
|
$13,016.29
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$12,495.64 |
| Rate for Payer: Aetna Commercial |
$10,022.54
|
| Rate for Payer: Anthem Medicaid |
$4,476.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,152.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$6,508.15
|
| Rate for Payer: Cash Price |
$6,508.15
|
| Rate for Payer: Cigna Commercial |
$10,803.52
|
| Rate for Payer: First Health Commercial |
$12,365.48
|
| Rate for Payer: Humana Commercial |
$11,063.85
|
| Rate for Payer: Humana KY Medicaid |
$4,476.30
|
| Rate for Payer: Humana Medicare Advantage |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$4,521.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,673.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,606.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,566.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,454.34
|
| Rate for Payer: Ohio Health Group HMO |
$9,762.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,413.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,324.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,981.24
|
| Rate for Payer: PHCS Commercial |
$12,495.64
|
| Rate for Payer: United Healthcare All Payer |
$11,454.34
|
|
|
ARISTADA PER MG (662MG SYR)
|
Facility
|
IP
|
$13,016.29
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,904.89 |
| Max. Negotiated Rate |
$12,495.64 |
| Rate for Payer: Aetna Commercial |
$10,022.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,152.71
|
| Rate for Payer: Cash Price |
$6,508.15
|
| Rate for Payer: Cigna Commercial |
$10,803.52
|
| Rate for Payer: First Health Commercial |
$12,365.48
|
| Rate for Payer: Humana Commercial |
$11,063.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,673.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,606.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,904.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,454.34
|
| Rate for Payer: Ohio Health Group HMO |
$9,762.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,413.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,324.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,981.24
|
| Rate for Payer: PHCS Commercial |
$12,495.64
|
| Rate for Payer: United Healthcare All Payer |
$11,454.34
|
|
|
ARISTADA PER MG (882MG SYR)
|
Facility
|
OP
|
$17,341.85
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$16,648.18 |
| Rate for Payer: Aetna Commercial |
$13,353.22
|
| Rate for Payer: Anthem Medicaid |
$5,963.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,526.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$8,670.92
|
| Rate for Payer: Cash Price |
$8,670.92
|
| Rate for Payer: Cigna Commercial |
$14,393.74
|
| Rate for Payer: First Health Commercial |
$16,474.76
|
| Rate for Payer: Humana Commercial |
$14,740.57
|
| Rate for Payer: Humana KY Medicaid |
$5,963.86
|
| Rate for Payer: Humana Medicare Advantage |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$6,024.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,220.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,798.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,083.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,260.83
|
| Rate for Payer: Ohio Health Group HMO |
$13,006.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,873.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,087.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,965.88
|
| Rate for Payer: PHCS Commercial |
$16,648.18
|
| Rate for Payer: United Healthcare All Payer |
$15,260.83
|
|
|
ARISTADA PER MG (882MG SYR)
|
Facility
|
IP
|
$17,341.85
|
|
|
Service Code
|
HCPCS J1944
|
| Hospital Charge Code |
25002205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,202.56 |
| Max. Negotiated Rate |
$16,648.18 |
| Rate for Payer: Aetna Commercial |
$13,353.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,526.64
|
| Rate for Payer: Cash Price |
$8,670.92
|
| Rate for Payer: Cigna Commercial |
$14,393.74
|
| Rate for Payer: First Health Commercial |
$16,474.76
|
| Rate for Payer: Humana Commercial |
$14,740.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,220.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,798.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,202.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,260.83
|
| Rate for Payer: Ohio Health Group HMO |
$13,006.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,873.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,087.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,965.88
|
| Rate for Payer: PHCS Commercial |
$16,648.18
|
| Rate for Payer: United Healthcare All Payer |
$15,260.83
|
|
|
ARIXTRA 0.5 MG (10 MG/0.8 ML)
|
Facility
|
IP
|
$323.32
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25003822
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.00 |
| Max. Negotiated Rate |
$310.39 |
| Rate for Payer: Aetna Commercial |
$248.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$252.19
|
| Rate for Payer: Cash Price |
$161.66
|
| Rate for Payer: Cigna Commercial |
$268.36
|
| Rate for Payer: First Health Commercial |
$307.15
|
| Rate for Payer: Humana Commercial |
$274.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.52
|
| Rate for Payer: Ohio Health Group HMO |
$242.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.09
|
| Rate for Payer: PHCS Commercial |
$310.39
|
| Rate for Payer: United Healthcare All Payer |
$284.52
|
|
|
ARIXTRA 0.5 MG (10 MG/0.8 ML)
|
Facility
|
OP
|
$323.32
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25003822
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.00 |
| Max. Negotiated Rate |
$310.39 |
| Rate for Payer: Aetna Commercial |
$248.96
|
| Rate for Payer: Anthem Medicaid |
$111.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$252.19
|
| Rate for Payer: Cash Price |
$161.66
|
| Rate for Payer: Cigna Commercial |
$268.36
|
| Rate for Payer: First Health Commercial |
$307.15
|
| Rate for Payer: Humana Commercial |
$274.82
|
| Rate for Payer: Humana KY Medicaid |
$111.19
|
| Rate for Payer: Kentucky WC Medicaid |
$112.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.52
|
| Rate for Payer: Ohio Health Group HMO |
$242.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.09
|
| Rate for Payer: PHCS Commercial |
$310.39
|
| Rate for Payer: United Healthcare All Payer |
$284.52
|
|
|
ARIXTRA 0.5 MG (7 MG/0.6 ML)
|
Facility
|
OP
|
$558.87
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25003823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.66 |
| Max. Negotiated Rate |
$536.52 |
| Rate for Payer: Aetna Commercial |
$430.33
|
| Rate for Payer: Anthem Medicaid |
$192.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.92
|
| Rate for Payer: Cash Price |
$279.44
|
| Rate for Payer: Cigna Commercial |
$463.86
|
| Rate for Payer: First Health Commercial |
$530.93
|
| Rate for Payer: Humana Commercial |
$475.04
|
| Rate for Payer: Humana KY Medicaid |
$192.20
|
| Rate for Payer: Kentucky WC Medicaid |
$194.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.81
|
| Rate for Payer: Ohio Health Group HMO |
$419.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.62
|
| Rate for Payer: PHCS Commercial |
$536.52
|
| Rate for Payer: United Healthcare All Payer |
$491.81
|
|
|
ARIXTRA 0.5 MG (7 MG/0.6 ML)
|
Facility
|
IP
|
$558.87
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25003823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.66 |
| Max. Negotiated Rate |
$536.52 |
| Rate for Payer: Aetna Commercial |
$430.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.92
|
| Rate for Payer: Cash Price |
$279.44
|
| Rate for Payer: Cigna Commercial |
$463.86
|
| Rate for Payer: First Health Commercial |
$530.93
|
| Rate for Payer: Humana Commercial |
$475.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.81
|
| Rate for Payer: Ohio Health Group HMO |
$419.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.62
|
| Rate for Payer: PHCS Commercial |
$536.52
|
| Rate for Payer: United Healthcare All Payer |
$491.81
|
|
|
ARIXTRA 5 MG SYRINGE
|
Facility
|
OP
|
$558.87
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25002152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.66 |
| Max. Negotiated Rate |
$536.52 |
| Rate for Payer: Aetna Commercial |
$430.33
|
| Rate for Payer: Anthem Medicaid |
$192.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.92
|
| Rate for Payer: Cash Price |
$279.44
|
| Rate for Payer: Cigna Commercial |
$463.86
|
| Rate for Payer: First Health Commercial |
$530.93
|
| Rate for Payer: Humana Commercial |
$475.04
|
| Rate for Payer: Humana KY Medicaid |
$192.20
|
| Rate for Payer: Kentucky WC Medicaid |
$194.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.81
|
| Rate for Payer: Ohio Health Group HMO |
$419.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.62
|
| Rate for Payer: PHCS Commercial |
$536.52
|
| Rate for Payer: United Healthcare All Payer |
$491.81
|
|
|
ARIXTRA 5 MG SYRINGE
|
Facility
|
IP
|
$558.87
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25002152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.66 |
| Max. Negotiated Rate |
$536.52 |
| Rate for Payer: Aetna Commercial |
$430.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.92
|
| Rate for Payer: Cash Price |
$279.44
|
| Rate for Payer: Cigna Commercial |
$463.86
|
| Rate for Payer: First Health Commercial |
$530.93
|
| Rate for Payer: Humana Commercial |
$475.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.81
|
| Rate for Payer: Ohio Health Group HMO |
$419.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.62
|
| Rate for Payer: PHCS Commercial |
$536.52
|
| Rate for Payer: United Healthcare All Payer |
$491.81
|
|
|
ARIXTRA(FONDAPARI SOD)2.5MGSYR
|
Facility
|
OP
|
$324.61
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25002151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.38 |
| Max. Negotiated Rate |
$311.63 |
| Rate for Payer: Aetna Commercial |
$249.95
|
| Rate for Payer: Anthem Medicaid |
$111.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.20
|
| Rate for Payer: Cash Price |
$162.30
|
| Rate for Payer: Cigna Commercial |
$269.43
|
| Rate for Payer: First Health Commercial |
$308.38
|
| Rate for Payer: Humana Commercial |
$275.92
|
| Rate for Payer: Humana KY Medicaid |
$111.63
|
| Rate for Payer: Kentucky WC Medicaid |
$112.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$285.66
|
| Rate for Payer: Ohio Health Group HMO |
$243.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$259.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.98
|
| Rate for Payer: PHCS Commercial |
$311.63
|
| Rate for Payer: United Healthcare All Payer |
$285.66
|
|
|
ARIXTRA(FONDAPARI SOD)2.5MGSYR
|
Facility
|
IP
|
$324.61
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
25002151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.38 |
| Max. Negotiated Rate |
$311.63 |
| Rate for Payer: Aetna Commercial |
$249.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.20
|
| Rate for Payer: Cash Price |
$162.30
|
| Rate for Payer: Cigna Commercial |
$269.43
|
| Rate for Payer: First Health Commercial |
$308.38
|
| Rate for Payer: Humana Commercial |
$275.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$285.66
|
| Rate for Payer: Ohio Health Group HMO |
$243.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$259.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.98
|
| Rate for Payer: PHCS Commercial |
$311.63
|
| Rate for Payer: United Healthcare All Payer |
$285.66
|
|
|
ARMADA BALLOON 10*20*135
|
Facility
|
IP
|
$1,889.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.70 |
| Max. Negotiated Rate |
$1,813.44 |
| Rate for Payer: Aetna Commercial |
$1,454.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,473.42
|
| Rate for Payer: Cash Price |
$944.50
|
| Rate for Payer: Cigna Commercial |
$1,567.87
|
| Rate for Payer: First Health Commercial |
$1,794.55
|
| Rate for Payer: Humana Commercial |
$1,605.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,394.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,662.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,511.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,643.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,303.41
|
| Rate for Payer: PHCS Commercial |
$1,813.44
|
| Rate for Payer: United Healthcare All Payer |
$1,662.32
|
|
|
ARMADA BALLOON 10*20*135
|
Facility
|
OP
|
$1,889.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.70 |
| Max. Negotiated Rate |
$1,813.44 |
| Rate for Payer: Aetna Commercial |
$1,454.53
|
| Rate for Payer: Anthem Medicaid |
$649.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,473.42
|
| Rate for Payer: Cash Price |
$944.50
|
| Rate for Payer: Cigna Commercial |
$1,567.87
|
| Rate for Payer: First Health Commercial |
$1,794.55
|
| Rate for Payer: Humana Commercial |
$1,605.65
|
| Rate for Payer: Humana KY Medicaid |
$649.63
|
| Rate for Payer: Kentucky WC Medicaid |
$656.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,394.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$662.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,662.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,511.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,643.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,303.41
|
| Rate for Payer: PHCS Commercial |
$1,813.44
|
| Rate for Payer: United Healthcare All Payer |
$1,662.32
|
|
|
ARMADA BALLOON 10*20*80
|
Facility
|
IP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.00 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$920.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,000.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$793.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
|
|
ARMADA BALLOON 10*20*80
|
Facility
|
OP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.00 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Anthem Medicaid |
$395.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Humana KY Medicaid |
$395.49
|
| Rate for Payer: Kentucky WC Medicaid |
$399.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$920.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,000.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$793.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
|
|
ARMADA BALLOON 10*40*135
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem Medicaid |
$603.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Humana KY Medicaid |
$603.89
|
| Rate for Payer: Kentucky WC Medicaid |
$610.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
ARMADA BALLOON 10*40*135
|
Facility
|
IP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
ARMADA BALLOON 10*40*80
|
Facility
|
IP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.00 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$920.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,000.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$793.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
|
|
ARMADA BALLOON 10*40*80
|
Facility
|
OP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.00 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Anthem Medicaid |
$395.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Humana KY Medicaid |
$395.49
|
| Rate for Payer: Kentucky WC Medicaid |
$399.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$920.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,000.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$793.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
|
|
ARMADA BALLOON 10*60*135
|
Facility
|
OP
|
$1,889.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.70 |
| Max. Negotiated Rate |
$1,813.44 |
| Rate for Payer: Aetna Commercial |
$1,454.53
|
| Rate for Payer: Anthem Medicaid |
$649.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,473.42
|
| Rate for Payer: Cash Price |
$944.50
|
| Rate for Payer: Cigna Commercial |
$1,567.87
|
| Rate for Payer: First Health Commercial |
$1,794.55
|
| Rate for Payer: Humana Commercial |
$1,605.65
|
| Rate for Payer: Humana KY Medicaid |
$649.63
|
| Rate for Payer: Kentucky WC Medicaid |
$656.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,394.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$662.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,662.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,511.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,643.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,303.41
|
| Rate for Payer: PHCS Commercial |
$1,813.44
|
| Rate for Payer: United Healthcare All Payer |
$1,662.32
|
|
