|
PRINIVIL (LISINOPRIL) 20MG TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904679961
|
| Hospital Charge Code |
25001234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PRINIVIL (LISINOPRIL) 5MG TAB
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 904679761
|
| Hospital Charge Code |
25001233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
PRINIVIL (LISINOPRIL) 5MG TAB
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 904679761
|
| Hospital Charge Code |
25001233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
PRIORITY ONE ASPIRATN CATH 6F
|
Facility
|
OP
|
$3,512.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem Medicaid |
$1,207.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Humana KY Medicaid |
$1,207.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,220.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,232.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
PRIORITY ONE ASPIRATN CATH 6F
|
Facility
|
IP
|
$3,512.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
PRISMASATE BGK4/2.5 CRRT SOL
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.76
|
| Rate for Payer: Humana Commercial |
$83.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.60
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASATE BGK4/2.5 CRRT SOL
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem Medicaid |
$33.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.76
|
| Rate for Payer: Humana Commercial |
$83.90
|
| Rate for Payer: Humana KY Medicaid |
$33.94
|
| Rate for Payer: Kentucky WC Medicaid |
$34.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.60
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASATE(BK2/0)5000MLCRRTSOL
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.76
|
| Rate for Payer: Humana Commercial |
$83.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.60
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASATE(BK2/0)5000MLCRRTSOL
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem Medicaid |
$33.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.76
|
| Rate for Payer: Humana Commercial |
$83.90
|
| Rate for Payer: Humana KY Medicaid |
$33.94
|
| Rate for Payer: Kentucky WC Medicaid |
$34.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.60
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASOL BGK2/0 5,000 ML SOLN
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
NDC 24571010206
|
| Hospital Charge Code |
25004234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem Medicaid |
$33.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.76
|
| Rate for Payer: Humana Commercial |
$83.90
|
| Rate for Payer: Humana KY Medicaid |
$33.94
|
| Rate for Payer: Kentucky WC Medicaid |
$34.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.60
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASOL BGK2/0 5,000 ML SOLN
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 24571010206
|
| Hospital Charge Code |
25004234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.76
|
| Rate for Payer: Humana Commercial |
$83.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.60
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISTIQ 100MG TABLET
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 59762122203
|
| Hospital Charge Code |
25001236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
PRISTIQ 100MG TABLET
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 59762122203
|
| Hospital Charge Code |
25001236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
PRISTIQ 25MG EQUIV TABLET ER
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 8121030
|
| Hospital Charge Code |
25003383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem Medicaid |
$10.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Humana KY Medicaid |
$10.87
|
| Rate for Payer: Kentucky WC Medicaid |
$10.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRISTIQ 25MG EQUIV TABLET ER
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 8121030
|
| Hospital Charge Code |
25003383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRISTIQ 50MG TABLET
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 8121101
|
| Hospital Charge Code |
25001237
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRISTIQ 50MG TABLET
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 8121101
|
| Hospital Charge Code |
25001237
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem Medicaid |
$10.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Humana KY Medicaid |
$10.87
|
| Rate for Payer: Kentucky WC Medicaid |
$10.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRIVIGEN 500mg (10gm) SDV
|
Facility
|
IP
|
$9,866.68
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,282.67 |
| Max. Negotiated Rate |
$9,472.01 |
| Rate for Payer: Aetna Commercial |
$7,597.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,696.01
|
| Rate for Payer: Cash Price |
$4,933.34
|
| Rate for Payer: Cigna Commercial |
$8,189.34
|
| Rate for Payer: First Health Commercial |
$9,373.35
|
| Rate for Payer: Humana Commercial |
$8,386.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,090.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,281.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,682.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,400.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,973.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,282.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,058.67
|
| Rate for Payer: PHCS Commercial |
$9,472.01
|
| Rate for Payer: United Healthcare All Payer |
$8,682.68
|
|
|
PRIVIGEN 500mg (10gm) SDV
|
Facility
|
OP
|
$9,866.68
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.29 |
| Max. Negotiated Rate |
$9,472.01 |
| Rate for Payer: Aetna Commercial |
$7,597.34
|
| Rate for Payer: Anthem Medicaid |
$3,393.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,696.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.19
|
| Rate for Payer: Cash Price |
$4,933.34
|
| Rate for Payer: Cash Price |
$4,933.34
|
| Rate for Payer: Cigna Commercial |
$8,189.34
|
| Rate for Payer: First Health Commercial |
$9,373.35
|
| Rate for Payer: Humana Commercial |
$8,386.68
|
| Rate for Payer: Humana KY Medicaid |
$3,393.15
|
| Rate for Payer: Humana Medicare Advantage |
$48.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,427.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,090.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,281.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,461.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,682.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,400.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,973.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,282.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,058.67
|
| Rate for Payer: PHCS Commercial |
$9,472.01
|
| Rate for Payer: United Healthcare All Payer |
$8,682.68
|
|
|
PRIVIGEN 500mg (20gm) SDV
|
Facility
|
IP
|
$19,733.36
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,565.34 |
| Max. Negotiated Rate |
$18,944.03 |
| Rate for Payer: Aetna Commercial |
$15,194.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,392.02
|
| Rate for Payer: Cash Price |
$9,866.68
|
| Rate for Payer: Cigna Commercial |
$16,378.69
|
| Rate for Payer: First Health Commercial |
$18,746.69
|
| Rate for Payer: Humana Commercial |
$16,773.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,181.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,563.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,920.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,365.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,800.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,946.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,565.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,117.34
|
| Rate for Payer: PHCS Commercial |
$18,944.03
|
| Rate for Payer: United Healthcare All Payer |
$17,365.36
|
|
|
PRIVIGEN 500mg (20gm) SDV
|
Facility
|
OP
|
$19,733.36
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.29 |
| Max. Negotiated Rate |
$18,944.03 |
| Rate for Payer: Aetna Commercial |
$15,194.69
|
| Rate for Payer: Anthem Medicaid |
$6,786.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,392.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.19
|
| Rate for Payer: Cash Price |
$9,866.68
|
| Rate for Payer: Cash Price |
$9,866.68
|
| Rate for Payer: Cigna Commercial |
$16,378.69
|
| Rate for Payer: First Health Commercial |
$18,746.69
|
| Rate for Payer: Humana Commercial |
$16,773.36
|
| Rate for Payer: Humana KY Medicaid |
$6,786.30
|
| Rate for Payer: Humana Medicare Advantage |
$48.29
|
| Rate for Payer: Kentucky WC Medicaid |
$6,855.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,181.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,563.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,922.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,365.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,800.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,946.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,565.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,117.34
|
| Rate for Payer: PHCS Commercial |
$18,944.03
|
| Rate for Payer: United Healthcare All Payer |
$17,365.36
|
|
|
PRIVIGEN 500mg (40gm) SDV
|
Facility
|
OP
|
$39,466.72
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.29 |
| Max. Negotiated Rate |
$37,888.05 |
| Rate for Payer: Aetna Commercial |
$30,389.37
|
| Rate for Payer: Anthem Medicaid |
$13,572.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,784.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.19
|
| Rate for Payer: Cash Price |
$19,733.36
|
| Rate for Payer: Cash Price |
$19,733.36
|
| Rate for Payer: Cigna Commercial |
$32,757.38
|
| Rate for Payer: First Health Commercial |
$37,493.38
|
| Rate for Payer: Humana Commercial |
$33,546.71
|
| Rate for Payer: Humana KY Medicaid |
$13,572.61
|
| Rate for Payer: Humana Medicare Advantage |
$48.29
|
| Rate for Payer: Kentucky WC Medicaid |
$13,710.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,362.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,126.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,844.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,730.71
|
| Rate for Payer: Ohio Health Group HMO |
$29,600.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,893.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,130.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,234.68
|
| Rate for Payer: PHCS Commercial |
$37,888.05
|
| Rate for Payer: United Healthcare All Payer |
$34,730.71
|
|
|
PRIVIGEN 500mg (40gm) SDV
|
Facility
|
IP
|
$39,466.72
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,130.67 |
| Max. Negotiated Rate |
$37,888.05 |
| Rate for Payer: Aetna Commercial |
$30,389.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,784.04
|
| Rate for Payer: Cash Price |
$19,733.36
|
| Rate for Payer: Cigna Commercial |
$32,757.38
|
| Rate for Payer: First Health Commercial |
$37,493.38
|
| Rate for Payer: Humana Commercial |
$33,546.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,362.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,126.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,840.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,730.71
|
| Rate for Payer: Ohio Health Group HMO |
$29,600.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,893.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,130.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,234.68
|
| Rate for Payer: PHCS Commercial |
$37,888.05
|
| Rate for Payer: United Healthcare All Payer |
$34,730.71
|
|
|
PRIVIGEN 500mg (5gm) SDV
|
Facility
|
OP
|
$4,933.34
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.29 |
| Max. Negotiated Rate |
$4,736.01 |
| Rate for Payer: Aetna Commercial |
$3,798.67
|
| Rate for Payer: Anthem Medicaid |
$1,696.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,848.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.19
|
| Rate for Payer: Cash Price |
$2,466.67
|
| Rate for Payer: Cash Price |
$2,466.67
|
| Rate for Payer: Cigna Commercial |
$4,094.67
|
| Rate for Payer: First Health Commercial |
$4,686.67
|
| Rate for Payer: Humana Commercial |
$4,193.34
|
| Rate for Payer: Humana KY Medicaid |
$1,696.58
|
| Rate for Payer: Humana Medicare Advantage |
$48.29
|
| Rate for Payer: Kentucky WC Medicaid |
$1,713.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,045.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,640.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,730.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,341.34
|
| Rate for Payer: Ohio Health Group HMO |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$986.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$641.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,529.34
|
| Rate for Payer: PHCS Commercial |
$4,736.01
|
| Rate for Payer: United Healthcare All Payer |
$4,341.34
|
|
|
PRIVIGEN 500mg (5gm) SDV
|
Facility
|
IP
|
$4,933.34
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$641.33 |
| Max. Negotiated Rate |
$4,736.01 |
| Rate for Payer: Aetna Commercial |
$3,798.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,848.01
|
| Rate for Payer: Cash Price |
$2,466.67
|
| Rate for Payer: Cigna Commercial |
$4,094.67
|
| Rate for Payer: First Health Commercial |
$4,686.67
|
| Rate for Payer: Humana Commercial |
$4,193.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,045.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,640.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,341.34
|
| Rate for Payer: Ohio Health Group HMO |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$986.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$641.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,529.34
|
| Rate for Payer: PHCS Commercial |
$4,736.01
|
| Rate for Payer: United Healthcare All Payer |
$4,341.34
|
|
