|
ACTEMRA 1mg (162mg PFS)
|
Facility
|
OP
|
$6,402.71
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25003875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$6,146.60 |
| Rate for Payer: Aetna Commercial |
$4,930.09
|
| Rate for Payer: Anthem Medicaid |
$2,201.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,994.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.26
|
| Rate for Payer: Cash Price |
$3,201.36
|
| Rate for Payer: Cash Price |
$3,201.36
|
| Rate for Payer: Cigna Commercial |
$5,314.25
|
| Rate for Payer: First Health Commercial |
$6,082.57
|
| Rate for Payer: Humana Commercial |
$5,442.30
|
| Rate for Payer: Humana KY Medicaid |
$2,201.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,224.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,250.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,725.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,246.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,634.38
|
| Rate for Payer: Ohio Health Group HMO |
$4,802.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$832.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,984.84
|
| Rate for Payer: PHCS Commercial |
$6,146.60
|
| Rate for Payer: United Healthcare All Payer |
$5,634.38
|
|
|
ACTEMRA 1mg (162mg PFS)
|
Facility
|
IP
|
$6,402.71
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25003875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$832.35 |
| Max. Negotiated Rate |
$6,146.60 |
| Rate for Payer: Aetna Commercial |
$4,930.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,994.11
|
| Rate for Payer: Cash Price |
$3,201.36
|
| Rate for Payer: Cigna Commercial |
$5,314.25
|
| Rate for Payer: First Health Commercial |
$6,082.57
|
| Rate for Payer: Humana Commercial |
$5,442.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,250.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,725.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,920.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,634.38
|
| Rate for Payer: Ohio Health Group HMO |
$4,802.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$832.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,984.84
|
| Rate for Payer: PHCS Commercial |
$6,146.60
|
| Rate for Payer: United Healthcare All Payer |
$5,634.38
|
|
|
ACTEMRA 1MG [200MG/10ML VIAL]
|
Facility
|
IP
|
$7,237.11
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$940.82 |
| Max. Negotiated Rate |
$6,947.63 |
| Rate for Payer: Aetna Commercial |
$5,572.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.95
|
| Rate for Payer: Cash Price |
$3,618.55
|
| Rate for Payer: Cigna Commercial |
$6,006.80
|
| Rate for Payer: First Health Commercial |
$6,875.25
|
| Rate for Payer: Humana Commercial |
$6,151.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,171.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.66
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,447.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$940.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,243.50
|
| Rate for Payer: PHCS Commercial |
$6,947.63
|
| Rate for Payer: United Healthcare All Payer |
$6,368.66
|
|
|
ACTEMRA 1MG [200MG/10ML VIAL]
|
Facility
|
OP
|
$7,237.11
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$6,947.63 |
| Rate for Payer: Aetna Commercial |
$5,572.57
|
| Rate for Payer: Anthem Medicaid |
$2,488.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.26
|
| Rate for Payer: Cash Price |
$3,618.55
|
| Rate for Payer: Cash Price |
$3,618.55
|
| Rate for Payer: Cigna Commercial |
$6,006.80
|
| Rate for Payer: First Health Commercial |
$6,875.25
|
| Rate for Payer: Humana Commercial |
$6,151.54
|
| Rate for Payer: Humana KY Medicaid |
$2,488.84
|
| Rate for Payer: Humana Medicare Advantage |
$6.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,514.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,538.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.66
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,447.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$940.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,243.50
|
| Rate for Payer: PHCS Commercial |
$6,947.63
|
| Rate for Payer: United Healthcare All Payer |
$6,368.66
|
|
|
ACTEMRA 1MG [400MG/20ML VIAL]
|
Facility
|
OP
|
$14,474.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$13,895.25 |
| Rate for Payer: Aetna Commercial |
$11,145.15
|
| Rate for Payer: Anthem Medicaid |
$4,977.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,289.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.26
|
| Rate for Payer: Cash Price |
$7,237.11
|
| Rate for Payer: Cash Price |
$7,237.11
|
| Rate for Payer: Cigna Commercial |
$12,013.60
|
| Rate for Payer: First Health Commercial |
$13,750.51
|
| Rate for Payer: Humana Commercial |
$12,303.09
|
| Rate for Payer: Humana KY Medicaid |
$4,977.68
|
| Rate for Payer: Humana Medicare Advantage |
$6.12
|
| Rate for Payer: Kentucky WC Medicaid |
$5,028.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,868.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,681.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,077.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,737.31
|
| Rate for Payer: Ohio Health Group HMO |
$10,855.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,894.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,881.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,487.01
|
| Rate for Payer: PHCS Commercial |
$13,895.25
|
| Rate for Payer: United Healthcare All Payer |
$12,737.31
|
|
|
ACTEMRA 1MG [400MG/20ML VIAL]
|
Facility
|
IP
|
$14,474.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,881.65 |
| Max. Negotiated Rate |
$13,895.25 |
| Rate for Payer: Aetna Commercial |
$11,145.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,289.89
|
| Rate for Payer: Cash Price |
$7,237.11
|
| Rate for Payer: Cigna Commercial |
$12,013.60
|
| Rate for Payer: First Health Commercial |
$13,750.51
|
| Rate for Payer: Humana Commercial |
$12,303.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,868.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,681.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,342.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,737.31
|
| Rate for Payer: Ohio Health Group HMO |
$10,855.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,894.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,881.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,487.01
|
| Rate for Payer: PHCS Commercial |
$13,895.25
|
| Rate for Payer: United Healthcare All Payer |
$12,737.31
|
|
|
ACTEMRA 1MG[80MG/4ML VIAL]
|
Facility
|
OP
|
$2,894.82
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$2,779.03 |
| Rate for Payer: Aetna Commercial |
$2,229.01
|
| Rate for Payer: Anthem Medicaid |
$995.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,257.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.26
|
| Rate for Payer: Cash Price |
$1,447.41
|
| Rate for Payer: Cash Price |
$1,447.41
|
| Rate for Payer: Cigna Commercial |
$2,402.70
|
| Rate for Payer: First Health Commercial |
$2,750.08
|
| Rate for Payer: Humana Commercial |
$2,460.60
|
| Rate for Payer: Humana KY Medicaid |
$995.53
|
| Rate for Payer: Humana Medicare Advantage |
$6.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1,005.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,015.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$578.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.39
|
| Rate for Payer: PHCS Commercial |
$2,779.03
|
| Rate for Payer: United Healthcare All Payer |
$2,547.44
|
|
|
ACTEMRA 1MG[80MG/4ML VIAL]
|
Facility
|
IP
|
$2,894.82
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.33 |
| Max. Negotiated Rate |
$2,779.03 |
| Rate for Payer: Aetna Commercial |
$2,229.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,257.96
|
| Rate for Payer: Cash Price |
$1,447.41
|
| Rate for Payer: Cigna Commercial |
$2,402.70
|
| Rate for Payer: First Health Commercial |
$2,750.08
|
| Rate for Payer: Humana Commercial |
$2,460.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$868.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$578.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.39
|
| Rate for Payer: PHCS Commercial |
$2,779.03
|
| Rate for Payer: United Healthcare All Payer |
$2,547.44
|
|
|
ACTH STIMULATION PANEL
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
HCPCS 80400
|
| Hospital Charge Code |
30000175
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.62 |
| Max. Negotiated Rate |
$247.68 |
| Rate for Payer: Aetna Commercial |
$198.66
|
| Rate for Payer: Anthem Medicaid |
$32.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$207.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.62
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$214.14
|
| Rate for Payer: First Health Commercial |
$245.10
|
| Rate for Payer: Humana Commercial |
$219.30
|
| Rate for Payer: Humana KY Medicaid |
$32.62
|
| Rate for Payer: Humana Medicare Advantage |
$32.62
|
| Rate for Payer: Kentucky WC Medicaid |
$32.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$211.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$190.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$227.04
|
| Rate for Payer: Ohio Health Group HMO |
$193.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.98
|
| Rate for Payer: PHCS Commercial |
$247.68
|
| Rate for Payer: United Healthcare All Payer |
$227.04
|
|
|
ACTH STIMULATION PANEL
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
HCPCS 80400
|
| Hospital Charge Code |
30000175
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.54 |
| Max. Negotiated Rate |
$247.68 |
| Rate for Payer: Aetna Commercial |
$198.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$207.17
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$214.14
|
| Rate for Payer: First Health Commercial |
$245.10
|
| Rate for Payer: Humana Commercial |
$219.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$211.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$190.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$227.04
|
| Rate for Payer: Ohio Health Group HMO |
$193.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.98
|
| Rate for Payer: PHCS Commercial |
$247.68
|
| Rate for Payer: United Healthcare All Payer |
$227.04
|
|
|
ACTIDOSE/AQUA(CHARC 50GM/240ML
|
Facility
|
IP
|
$35.92
|
|
|
Service Code
|
NDC 574052176
|
| Hospital Charge Code |
25000145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.14
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIDOSE/AQUA(CHARC 50GM/240ML
|
Facility
|
OP
|
$35.92
|
|
|
Service Code
|
NDC 574052176
|
| Hospital Charge Code |
25000145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem Medicaid |
$12.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Humana KY Medicaid |
$12.35
|
| Rate for Payer: Kentucky WC Medicaid |
$12.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.14
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIDOSE/SORBITOL(C 50GM/240ML
|
Facility
|
OP
|
$35.92
|
|
|
Service Code
|
NDC 574052076
|
| Hospital Charge Code |
25000146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Anthem Medicaid |
$12.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Humana KY Medicaid |
$12.35
|
| Rate for Payer: Kentucky WC Medicaid |
$12.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.14
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIDOSE/SORBITOL(C 50GM/240ML
|
Facility
|
IP
|
$35.92
|
|
|
Service Code
|
NDC 574052076
|
| Hospital Charge Code |
25000146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.14
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIGALL (URSODIOL) 300MG/1CAP
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
NDC 527132601
|
| Hospital Charge Code |
25000147
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Aetna Commercial |
$7.12
|
| Rate for Payer: Anthem Medicaid |
$3.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.22
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cigna Commercial |
$7.68
|
| Rate for Payer: First Health Commercial |
$8.79
|
| Rate for Payer: Humana Commercial |
$7.86
|
| Rate for Payer: Humana KY Medicaid |
$3.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.14
|
| Rate for Payer: Ohio Health Group HMO |
$6.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Payer |
$8.14
|
|
|
ACTIGALL (URSODIOL) 300MG/1CAP
|
Facility
|
IP
|
$9.25
|
|
|
Service Code
|
NDC 527132601
|
| Hospital Charge Code |
25000147
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Aetna Commercial |
$7.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.22
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cigna Commercial |
$7.68
|
| Rate for Payer: First Health Commercial |
$8.79
|
| Rate for Payer: Humana Commercial |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.14
|
| Rate for Payer: Ohio Health Group HMO |
$6.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Payer |
$8.14
|
|
|
ACTIGRAPHY 72 HRS TO 14 DAYS
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 95803
|
| Hospital Charge Code |
92000012
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
ACTIGRAPHY 72 HRS TO 14 DAYS
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS 95803
|
| Hospital Charge Code |
92000012
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
ACTIVASE 1MG (2MG/2ML) ADD GTT
|
Facility
|
IP
|
$959.25
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25002369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.70 |
| Max. Negotiated Rate |
$920.88 |
| Rate for Payer: Aetna Commercial |
$738.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.22
|
| Rate for Payer: Cash Price |
$479.62
|
| Rate for Payer: Cigna Commercial |
$796.18
|
| Rate for Payer: First Health Commercial |
$911.29
|
| Rate for Payer: Humana Commercial |
$815.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$844.14
|
| Rate for Payer: Ohio Health Group HMO |
$719.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$191.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.37
|
| Rate for Payer: PHCS Commercial |
$920.88
|
| Rate for Payer: United Healthcare All Payer |
$844.14
|
|
|
ACTIVASE 1MG (2MG/2ML) ADD GTT
|
Facility
|
OP
|
$959.25
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25002369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.97 |
| Max. Negotiated Rate |
$920.88 |
| Rate for Payer: Aetna Commercial |
$738.62
|
| Rate for Payer: Anthem Medicaid |
$329.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$88.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$124.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.11
|
| Rate for Payer: Cash Price |
$479.62
|
| Rate for Payer: Cash Price |
$479.62
|
| Rate for Payer: Cigna Commercial |
$796.18
|
| Rate for Payer: First Health Commercial |
$911.29
|
| Rate for Payer: Humana Commercial |
$815.36
|
| Rate for Payer: Humana KY Medicaid |
$329.89
|
| Rate for Payer: Humana Medicare Advantage |
$88.97
|
| Rate for Payer: Kentucky WC Medicaid |
$333.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$336.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$844.14
|
| Rate for Payer: Ohio Health Group HMO |
$719.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$191.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$297.37
|
| Rate for Payer: PHCS Commercial |
$920.88
|
| Rate for Payer: United Healthcare All Payer |
$844.14
|
|
|
ACTIVASE 1mg (2mg/2mL Syringe)
|
Facility
|
OP
|
$904.75
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25004164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.97 |
| Max. Negotiated Rate |
$868.56 |
| Rate for Payer: Aetna Commercial |
$696.66
|
| Rate for Payer: Anthem Medicaid |
$311.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$88.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$124.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.11
|
| Rate for Payer: Cash Price |
$452.38
|
| Rate for Payer: Cash Price |
$452.38
|
| Rate for Payer: Cigna Commercial |
$750.94
|
| Rate for Payer: First Health Commercial |
$859.51
|
| Rate for Payer: Humana Commercial |
$769.04
|
| Rate for Payer: Humana KY Medicaid |
$311.14
|
| Rate for Payer: Humana Medicare Advantage |
$88.97
|
| Rate for Payer: Kentucky WC Medicaid |
$314.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$741.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$317.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.18
|
| Rate for Payer: Ohio Health Group HMO |
$678.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.47
|
| Rate for Payer: PHCS Commercial |
$868.56
|
| Rate for Payer: United Healthcare All Payer |
$796.18
|
|
|
ACTIVASE 1mg (2mg/2mL Syringe)
|
Facility
|
IP
|
$904.75
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25004164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.62 |
| Max. Negotiated Rate |
$868.56 |
| Rate for Payer: Aetna Commercial |
$696.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.70
|
| Rate for Payer: Cash Price |
$452.38
|
| Rate for Payer: Cigna Commercial |
$750.94
|
| Rate for Payer: First Health Commercial |
$859.51
|
| Rate for Payer: Humana Commercial |
$769.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$741.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.18
|
| Rate for Payer: Ohio Health Group HMO |
$678.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.47
|
| Rate for Payer: PHCS Commercial |
$868.56
|
| Rate for Payer: United Healthcare All Payer |
$796.18
|
|
|
ACTIVASE 1mg (45mg VIAL)
|
Facility
|
IP
|
$21,582.87
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,805.77 |
| Max. Negotiated Rate |
$20,719.56 |
| Rate for Payer: Aetna Commercial |
$16,618.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,834.64
|
| Rate for Payer: Cash Price |
$10,791.43
|
| Rate for Payer: Cigna Commercial |
$17,913.78
|
| Rate for Payer: First Health Commercial |
$20,503.73
|
| Rate for Payer: Humana Commercial |
$18,345.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,697.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,928.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,474.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,992.93
|
| Rate for Payer: Ohio Health Group HMO |
$16,187.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,316.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,805.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,690.69
|
| Rate for Payer: PHCS Commercial |
$20,719.56
|
| Rate for Payer: United Healthcare All Payer |
$18,992.93
|
|
|
ACTIVASE 1mg (45mg VIAL)
|
Facility
|
OP
|
$21,582.87
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.97 |
| Max. Negotiated Rate |
$20,719.56 |
| Rate for Payer: Aetna Commercial |
$16,618.81
|
| Rate for Payer: Anthem Medicaid |
$7,422.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$88.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,834.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$124.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.11
|
| Rate for Payer: Cash Price |
$10,791.43
|
| Rate for Payer: Cash Price |
$10,791.43
|
| Rate for Payer: Cigna Commercial |
$17,913.78
|
| Rate for Payer: First Health Commercial |
$20,503.73
|
| Rate for Payer: Humana Commercial |
$18,345.44
|
| Rate for Payer: Humana KY Medicaid |
$7,422.35
|
| Rate for Payer: Humana Medicare Advantage |
$88.97
|
| Rate for Payer: Kentucky WC Medicaid |
$7,497.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,697.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,928.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,571.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,992.93
|
| Rate for Payer: Ohio Health Group HMO |
$16,187.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,316.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,805.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,690.69
|
| Rate for Payer: PHCS Commercial |
$20,719.56
|
| Rate for Payer: United Healthcare All Payer |
$18,992.93
|
|
|
ACTIVASE 1mg (5mg VIAL)
|
Facility
|
IP
|
$2,398.11
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$311.75 |
| Max. Negotiated Rate |
$2,302.19 |
| Rate for Payer: Aetna Commercial |
$1,846.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,870.53
|
| Rate for Payer: Cash Price |
$1,199.06
|
| Rate for Payer: Cigna Commercial |
$1,990.43
|
| Rate for Payer: First Health Commercial |
$2,278.20
|
| Rate for Payer: Humana Commercial |
$2,038.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,966.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,769.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$719.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,110.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,798.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$479.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$311.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$743.41
|
| Rate for Payer: PHCS Commercial |
$2,302.19
|
| Rate for Payer: United Healthcare All Payer |
$2,110.34
|
|
