|
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 |
$39.89 |
| 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 |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| 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 |
$54.88
|
| 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 |
$65.86
|
| 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 |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
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 |
$94.15 |
| 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 |
$94.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$131.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$127.10
|
| 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 |
$94.15
|
| Rate for Payer: Kentucky WC Medicaid |
$333.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.98
|
| 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 |
$767.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.88
|
| Rate for Payer: PHCS Commercial |
$920.88
|
| Rate for Payer: United Healthcare All Payer |
$844.14
|
|
|
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 |
$287.77 |
| 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 |
$786.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.77
|
| 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 |
$767.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.88
|
| 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 |
$94.15 |
| 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 |
$94.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$131.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$127.10
|
| 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 |
$94.15
|
| Rate for Payer: Kentucky WC Medicaid |
$314.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$741.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.98
|
| 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 |
$723.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$787.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.28
|
| 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 |
$271.43 |
| Max. Negotiated Rate |
$868.56 |
| Rate for Payer: Aetna Commercial |
$696.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.71
|
| 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 |
$741.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.43
|
| 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 |
$723.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$787.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.28
|
| Rate for Payer: PHCS Commercial |
$868.56
|
| Rate for Payer: United Healthcare All Payer |
$796.18
|
|
|
ACTIVASE 1mg (45mg VIAL)
|
Facility
|
OP
|
$21,582.87
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| 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 |
$94.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,834.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$131.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$127.10
|
| 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 |
$94.15
|
| 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 |
$112.98
|
| 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 |
$17,266.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,777.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,892.18
|
| Rate for Payer: PHCS Commercial |
$20,719.56
|
| Rate for Payer: United Healthcare All Payer |
$18,992.93
|
|
|
ACTIVASE 1mg (45mg VIAL)
|
Facility
|
IP
|
$21,582.87
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,474.86 |
| 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 |
$17,266.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,777.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,892.18
|
| 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 |
$719.43 |
| 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 |
$1,918.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,086.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,654.70
|
| Rate for Payer: PHCS Commercial |
$2,302.19
|
| Rate for Payer: United Healthcare All Payer |
$2,110.34
|
|
|
ACTIVASE 1mg (5mg VIAL)
|
Facility
|
OP
|
$2,398.11
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$2,302.19 |
| Rate for Payer: Aetna Commercial |
$1,846.54
|
| Rate for Payer: Anthem Medicaid |
$824.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$94.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,870.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$131.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$127.10
|
| Rate for Payer: Cash Price |
$1,199.06
|
| 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: Humana KY Medicaid |
$824.71
|
| Rate for Payer: Humana Medicare Advantage |
$94.15
|
| Rate for Payer: Kentucky WC Medicaid |
$833.10
|
| 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 |
$112.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$841.26
|
| 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 |
$1,918.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,086.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,654.70
|
| Rate for Payer: PHCS Commercial |
$2,302.19
|
| Rate for Payer: United Healthcare All Payer |
$2,110.34
|
|
|
ACTIVASE 50MG VIAL
|
Facility
|
OP
|
$23,980.98
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003890
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$23,021.74 |
| Rate for Payer: Aetna Commercial |
$18,465.35
|
| Rate for Payer: Anthem Medicaid |
$8,247.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$94.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,705.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$131.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$127.10
|
| Rate for Payer: Cash Price |
$11,990.49
|
| Rate for Payer: Cash Price |
$11,990.49
|
| Rate for Payer: Cigna Commercial |
$19,904.21
|
| Rate for Payer: First Health Commercial |
$22,781.93
|
| Rate for Payer: Humana Commercial |
$20,383.83
|
| Rate for Payer: Humana KY Medicaid |
$8,247.06
|
| Rate for Payer: Humana Medicare Advantage |
$94.15
|
| Rate for Payer: Kentucky WC Medicaid |
$8,330.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,664.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,697.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,412.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,103.26
|
| Rate for Payer: Ohio Health Group HMO |
$17,985.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,184.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,863.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,546.88
|
| Rate for Payer: PHCS Commercial |
$23,021.74
|
| Rate for Payer: United Healthcare All Payer |
$21,103.26
|
|
|
ACTIVASE 50MG VIAL
|
Facility
|
IP
|
$23,980.98
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
25003890
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,194.29 |
| Max. Negotiated Rate |
$23,021.74 |
| Rate for Payer: Aetna Commercial |
$18,465.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,705.16
|
| Rate for Payer: Cash Price |
$11,990.49
|
| Rate for Payer: Cigna Commercial |
$19,904.21
|
| Rate for Payer: First Health Commercial |
$22,781.93
|
| Rate for Payer: Humana Commercial |
$20,383.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,664.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,697.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,194.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,103.26
|
| Rate for Payer: Ohio Health Group HMO |
$17,985.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,184.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,863.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,546.88
|
| Rate for Payer: PHCS Commercial |
$23,021.74
|
| Rate for Payer: United Healthcare All Payer |
$21,103.26
|
|
|
ACTIVATED CLOTTING TIME (ACT)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 85347
|
| Hospital Charge Code |
30000598
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.18
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
ACTIVATED CLOTTING TIME (ACT)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 85347
|
| Hospital Charge Code |
30000598
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$4.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.28
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$4.28
|
| Rate for Payer: Humana Medicare Advantage |
$4.28
|
| Rate for Payer: Kentucky WC Medicaid |
$4.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
ACTONEL 150MG TABLET
|
Facility
|
IP
|
$539.33
|
|
|
Service Code
|
NDC 430047801
|
| Hospital Charge Code |
25000149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.80 |
| Max. Negotiated Rate |
$517.76 |
| Rate for Payer: Aetna Commercial |
$415.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$420.68
|
| Rate for Payer: Cash Price |
$269.66
|
| Rate for Payer: Cigna Commercial |
$447.64
|
| Rate for Payer: First Health Commercial |
$512.36
|
| Rate for Payer: Humana Commercial |
$458.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$474.61
|
| Rate for Payer: Ohio Health Group HMO |
$404.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$431.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.14
|
| Rate for Payer: PHCS Commercial |
$517.76
|
| Rate for Payer: United Healthcare All Payer |
$474.61
|
|
|
ACTONEL 150MG TABLET
|
Facility
|
OP
|
$539.33
|
|
|
Service Code
|
NDC 430047801
|
| Hospital Charge Code |
25000149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.80 |
| Max. Negotiated Rate |
$517.76 |
| Rate for Payer: Aetna Commercial |
$415.28
|
| Rate for Payer: Anthem Medicaid |
$185.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$420.68
|
| Rate for Payer: Cash Price |
$269.66
|
| Rate for Payer: Cigna Commercial |
$447.64
|
| Rate for Payer: First Health Commercial |
$512.36
|
| Rate for Payer: Humana Commercial |
$458.43
|
| Rate for Payer: Humana KY Medicaid |
$185.48
|
| Rate for Payer: Kentucky WC Medicaid |
$187.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$474.61
|
| Rate for Payer: Ohio Health Group HMO |
$404.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$431.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.14
|
| Rate for Payer: PHCS Commercial |
$517.76
|
| Rate for Payer: United Healthcare All Payer |
$474.61
|
|
|
ACTONEL(ISEDRONATE)30MG TAB
|
Facility
|
IP
|
$87.56
|
|
|
Service Code
|
NDC 93310056
|
| Hospital Charge Code |
25000150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.27 |
| Max. Negotiated Rate |
$84.06 |
| Rate for Payer: Aetna Commercial |
$67.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.30
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Cigna Commercial |
$72.67
|
| Rate for Payer: First Health Commercial |
$83.18
|
| Rate for Payer: Humana Commercial |
$74.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.05
|
| Rate for Payer: Ohio Health Group HMO |
$65.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.42
|
| Rate for Payer: PHCS Commercial |
$84.06
|
| Rate for Payer: United Healthcare All Payer |
$77.05
|
|
|
ACTONEL(ISEDRONATE)30MG TAB
|
Facility
|
OP
|
$87.56
|
|
|
Service Code
|
NDC 93310056
|
| Hospital Charge Code |
25000150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.27 |
| Max. Negotiated Rate |
$84.06 |
| Rate for Payer: Aetna Commercial |
$67.42
|
| Rate for Payer: Anthem Medicaid |
$30.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.30
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Cigna Commercial |
$72.67
|
| Rate for Payer: First Health Commercial |
$83.18
|
| Rate for Payer: Humana Commercial |
$74.43
|
| Rate for Payer: Humana KY Medicaid |
$30.11
|
| Rate for Payer: Kentucky WC Medicaid |
$30.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.05
|
| Rate for Payer: Ohio Health Group HMO |
$65.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.42
|
| Rate for Payer: PHCS Commercial |
$84.06
|
| Rate for Payer: United Healthcare All Payer |
$77.05
|
|
|
ACTONEL(RISEDRON SOD) 35MG TAB
|
Facility
|
IP
|
$157.25
|
|
|
Service Code
|
NDC 430047203
|
| Hospital Charge Code |
25000151
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.17 |
| Max. Negotiated Rate |
$150.96 |
| Rate for Payer: Aetna Commercial |
$121.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$122.66
|
| Rate for Payer: Cash Price |
$78.62
|
| Rate for Payer: Cigna Commercial |
$130.52
|
| Rate for Payer: First Health Commercial |
$149.39
|
| Rate for Payer: Humana Commercial |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$128.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$138.38
|
| Rate for Payer: Ohio Health Group HMO |
$117.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.50
|
| Rate for Payer: PHCS Commercial |
$150.96
|
| Rate for Payer: United Healthcare All Payer |
$138.38
|
|
|
ACTONEL(RISEDRON SOD) 35MG TAB
|
Facility
|
OP
|
$157.25
|
|
|
Service Code
|
NDC 430047203
|
| Hospital Charge Code |
25000151
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.17 |
| Max. Negotiated Rate |
$150.96 |
| Rate for Payer: Aetna Commercial |
$121.08
|
| Rate for Payer: Anthem Medicaid |
$54.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$122.66
|
| Rate for Payer: Cash Price |
$78.62
|
| Rate for Payer: Cigna Commercial |
$130.52
|
| Rate for Payer: First Health Commercial |
$149.39
|
| Rate for Payer: Humana Commercial |
$133.66
|
| Rate for Payer: Humana KY Medicaid |
$54.08
|
| Rate for Payer: Kentucky WC Medicaid |
$54.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$128.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$138.38
|
| Rate for Payer: Ohio Health Group HMO |
$117.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.50
|
| Rate for Payer: PHCS Commercial |
$150.96
|
| Rate for Payer: United Healthcare All Payer |
$138.38
|
|
|
ACTOS (PIOGLITAZOME) 15MG TAB
|
Facility
|
OP
|
$9.05
|
|
|
Service Code
|
NDC 60687039101
|
| Hospital Charge Code |
25000152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
ACTOS (PIOGLITAZOME) 15MG TAB
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 60687039101
|
| Hospital Charge Code |
25000152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
ACULAR 0.5% OPHTH SOL
|
Facility
|
OP
|
$1.81
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
25000153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Anthem Medicaid |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.41
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$1.50
|
| Rate for Payer: First Health Commercial |
$1.72
|
| Rate for Payer: Humana Commercial |
$1.54
|
| Rate for Payer: Humana KY Medicaid |
$0.62
|
| Rate for Payer: Kentucky WC Medicaid |
$0.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.59
|
| Rate for Payer: Ohio Health Group HMO |
$1.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.25
|
| Rate for Payer: PHCS Commercial |
$1.74
|
| Rate for Payer: United Healthcare All Payer |
$1.59
|
|
|
ACULAR 0.5% OPHTH SOL
|
Facility
|
IP
|
$1.81
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
25000153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.41
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$1.50
|
| Rate for Payer: First Health Commercial |
$1.72
|
| Rate for Payer: Humana Commercial |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.59
|
| Rate for Payer: Ohio Health Group HMO |
$1.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.25
|
| Rate for Payer: PHCS Commercial |
$1.74
|
| Rate for Payer: United Healthcare All Payer |
$1.59
|
|
|
ACULAR LS EYE DROPS 5ML
|
Facility
|
OP
|
$8.75
|
|
|
Service Code
|
NDC 23927705
|
| Hospital Charge Code |
25002801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna Commercial |
$6.74
|
| Rate for Payer: Anthem Medicaid |
$3.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna Commercial |
$7.26
|
| Rate for Payer: First Health Commercial |
$8.31
|
| Rate for Payer: Humana Commercial |
$7.44
|
| Rate for Payer: Humana KY Medicaid |
$3.01
|
| Rate for Payer: Kentucky WC Medicaid |
$3.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.70
|
| Rate for Payer: Ohio Health Group HMO |
$6.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.04
|
| Rate for Payer: PHCS Commercial |
$8.40
|
| Rate for Payer: United Healthcare All Payer |
$7.70
|
|
|
ACULAR LS EYE DROPS 5ML
|
Facility
|
IP
|
$8.75
|
|
|
Service Code
|
NDC 23927705
|
| Hospital Charge Code |
25002801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna Commercial |
$6.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna Commercial |
$7.26
|
| Rate for Payer: First Health Commercial |
$8.31
|
| Rate for Payer: Humana Commercial |
$7.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.70
|
| Rate for Payer: Ohio Health Group HMO |
$6.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.04
|
| Rate for Payer: PHCS Commercial |
$8.40
|
| Rate for Payer: United Healthcare All Payer |
$7.70
|
|
