|
PENILE VASCULAR STUDY
|
Facility
|
IP
|
$1,048.00
|
|
|
Service Code
|
HCPCS 93980
|
| Hospital Charge Code |
92100016
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$136.24 |
| Max. Negotiated Rate |
$1,006.08 |
| Rate for Payer: Aetna Commercial |
$806.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$817.44
|
| Rate for Payer: Cash Price |
$524.00
|
| Rate for Payer: Cigna Commercial |
$869.84
|
| Rate for Payer: First Health Commercial |
$995.60
|
| Rate for Payer: Humana Commercial |
$890.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$859.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$773.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$314.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$922.24
|
| Rate for Payer: Ohio Health Group HMO |
$786.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$209.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$324.88
|
| Rate for Payer: PHCS Commercial |
$1,006.08
|
| Rate for Payer: United Healthcare All Payer |
$922.24
|
|
|
PENILE VASCULAR STUDY
|
Facility
|
OP
|
$1,048.00
|
|
|
Service Code
|
HCPCS 93980
|
| Hospital Charge Code |
92100016
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,006.08 |
| Rate for Payer: Aetna Commercial |
$806.96
|
| Rate for Payer: Anthem Medicaid |
$360.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$817.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$524.00
|
| Rate for Payer: Cash Price |
$524.00
|
| Rate for Payer: Cigna Commercial |
$869.84
|
| Rate for Payer: First Health Commercial |
$995.60
|
| Rate for Payer: Humana Commercial |
$890.80
|
| Rate for Payer: Humana KY Medicaid |
$360.41
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$364.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$859.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$773.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$367.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$922.24
|
| Rate for Payer: Ohio Health Group HMO |
$786.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$209.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$324.88
|
| Rate for Payer: PHCS Commercial |
$1,006.08
|
| Rate for Payer: United Healthcare All Payer |
$922.24
|
|
|
PENILE VASCULAR STUDY
|
Professional
|
Both
|
$1,048.00
|
|
|
Service Code
|
HCPCS 93980
|
| Hospital Charge Code |
92100016
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$84.01 |
| Max. Negotiated Rate |
$1,048.00 |
| Rate for Payer: Aetna Commercial |
$287.23
|
| Rate for Payer: Anthem Medicaid |
$175.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,048.00
|
| Rate for Payer: Cash Price |
$524.00
|
| Rate for Payer: Cash Price |
$524.00
|
| Rate for Payer: Cigna Commercial |
$223.00
|
| Rate for Payer: Healthspan PPO |
$306.83
|
| Rate for Payer: Humana Medicaid |
$175.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$179.16
|
| Rate for Payer: Molina Healthcare Passport |
$175.65
|
| Rate for Payer: Multiplan PHCS |
$628.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$733.60
|
| Rate for Payer: UHCCP Medicaid |
$366.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$177.41
|
|
|
PENILE VASCULAR STUDY(P
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 93980
|
| Hospital Charge Code |
921P0016
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$84.01 |
| Max. Negotiated Rate |
$306.83 |
| Rate for Payer: Aetna Commercial |
$287.23
|
| Rate for Payer: Anthem Medicaid |
$175.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$223.00
|
| Rate for Payer: Healthspan PPO |
$306.83
|
| Rate for Payer: Humana Medicaid |
$175.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$179.16
|
| Rate for Payer: Molina Healthcare Passport |
$175.65
|
| Rate for Payer: Multiplan PHCS |
$156.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.00
|
| Rate for Payer: UHCCP Medicaid |
$91.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$177.41
|
|
|
PENILE VASCULAR STUDY(T
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
HCPCS 93980
|
| Hospital Charge Code |
921T0016
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$756.48 |
| Rate for Payer: Aetna Commercial |
$606.76
|
| Rate for Payer: Anthem Medicaid |
$270.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$614.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cigna Commercial |
$654.04
|
| Rate for Payer: First Health Commercial |
$748.60
|
| Rate for Payer: Humana Commercial |
$669.80
|
| Rate for Payer: Humana KY Medicaid |
$270.99
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$273.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$581.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$276.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$693.44
|
| Rate for Payer: Ohio Health Group HMO |
$591.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.28
|
| Rate for Payer: PHCS Commercial |
$756.48
|
| Rate for Payer: United Healthcare All Payer |
$693.44
|
|
|
PENILE VASCULAR STUDY(T
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
HCPCS 93980
|
| Hospital Charge Code |
921T0016
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$102.44 |
| Max. Negotiated Rate |
$756.48 |
| Rate for Payer: Aetna Commercial |
$606.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$614.64
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cigna Commercial |
$654.04
|
| Rate for Payer: First Health Commercial |
$748.60
|
| Rate for Payer: Humana Commercial |
$669.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$581.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$236.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$693.44
|
| Rate for Payer: Ohio Health Group HMO |
$591.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.28
|
| Rate for Payer: PHCS Commercial |
$756.48
|
| Rate for Payer: United Healthcare All Payer |
$693.44
|
|
|
PENIS PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$25,394.45
|
|
|
Service Code
|
MSDRG 709
|
| Min. Negotiated Rate |
$17,231.95 |
| Max. Negotiated Rate |
$25,394.45 |
| Rate for Payer: Anthem Medicaid |
$17,231.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18,138.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25,394.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$24,487.50
|
| Rate for Payer: Humana KY Medicaid |
$17,231.95
|
| Rate for Payer: Humana Medicare Advantage |
$18,138.89
|
| Rate for Payer: Kentucky WC Medicaid |
$17,404.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,766.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,576.58
|
|
|
PENIS PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$15,176.08
|
|
|
Service Code
|
MSDRG 710
|
| Min. Negotiated Rate |
$10,298.06 |
| Max. Negotiated Rate |
$15,176.08 |
| Rate for Payer: Anthem Medicaid |
$10,298.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,840.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,176.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,634.08
|
| Rate for Payer: Humana KY Medicaid |
$10,298.06
|
| Rate for Payer: Humana Medicare Advantage |
$10,840.06
|
| Rate for Payer: Kentucky WC Medicaid |
$10,401.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,008.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,504.02
|
|
|
PENTAM-300 (PENTAMID 300MG/3ML
|
Facility
|
IP
|
$594.89
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.34 |
| Max. Negotiated Rate |
$571.09 |
| Rate for Payer: Aetna Commercial |
$458.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$464.01
|
| Rate for Payer: Cash Price |
$297.44
|
| Rate for Payer: Cigna Commercial |
$493.76
|
| Rate for Payer: First Health Commercial |
$565.15
|
| Rate for Payer: Humana Commercial |
$505.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$439.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$523.50
|
| Rate for Payer: Ohio Health Group HMO |
$446.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.42
|
| Rate for Payer: PHCS Commercial |
$571.09
|
| Rate for Payer: United Healthcare All Payer |
$523.50
|
|
|
PENTAM-300 (PENTAMID 300MG/3ML
|
Facility
|
OP
|
$594.89
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.34 |
| Max. Negotiated Rate |
$571.09 |
| Rate for Payer: Aetna Commercial |
$458.07
|
| Rate for Payer: Anthem Medicaid |
$204.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$464.01
|
| Rate for Payer: Cash Price |
$297.44
|
| Rate for Payer: Cigna Commercial |
$493.76
|
| Rate for Payer: First Health Commercial |
$565.15
|
| Rate for Payer: Humana Commercial |
$505.66
|
| Rate for Payer: Humana KY Medicaid |
$204.58
|
| Rate for Payer: Kentucky WC Medicaid |
$206.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$439.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$208.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$523.50
|
| Rate for Payer: Ohio Health Group HMO |
$446.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.42
|
| Rate for Payer: PHCS Commercial |
$571.09
|
| Rate for Payer: United Healthcare All Payer |
$523.50
|
|
|
PENTASA (MESALAMINE)CR 250MG C
|
Facility
|
OP
|
$11.04
|
|
|
Service Code
|
NDC 54092018981
|
| Hospital Charge Code |
25001169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Aetna Commercial |
$8.50
|
| Rate for Payer: Anthem Medicaid |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.61
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Cigna Commercial |
$9.16
|
| Rate for Payer: First Health Commercial |
$10.49
|
| Rate for Payer: Humana Commercial |
$9.38
|
| Rate for Payer: Humana KY Medicaid |
$3.80
|
| Rate for Payer: Kentucky WC Medicaid |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.72
|
| Rate for Payer: Ohio Health Group HMO |
$8.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$10.60
|
| Rate for Payer: United Healthcare All Payer |
$9.72
|
|
|
PENTASA (MESALAMINE)CR 250MG C
|
Facility
|
IP
|
$11.04
|
|
|
Service Code
|
NDC 54092018981
|
| Hospital Charge Code |
25001169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Aetna Commercial |
$8.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.61
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Cigna Commercial |
$9.16
|
| Rate for Payer: First Health Commercial |
$10.49
|
| Rate for Payer: Humana Commercial |
$9.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.72
|
| Rate for Payer: Ohio Health Group HMO |
$8.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$10.60
|
| Rate for Payer: United Healthcare All Payer |
$9.72
|
|
|
PEN-VEE K 500mg Tablet
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 57237004101
|
| Hospital Charge Code |
25004084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
PEN-VEE K 500mg Tablet
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 57237004101
|
| Hospital Charge Code |
25004084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
PEN-VEE K (PEN V PO 250MG/1TAB
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 143983701
|
| Hospital Charge Code |
25001170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
PEN-VEE K (PEN V PO 250MG/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 143983701
|
| Hospital Charge Code |
25001170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
PEN-V K 250MG/5ML SUSPENSION
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 93412774
|
| Hospital Charge Code |
25003345
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
PEN-V K 250MG/5ML SUSPENSION
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 93412774
|
| Hospital Charge Code |
25003345
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
PEPCID 20MG
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$61.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.79
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cigna Commercial |
$66.82
|
| Rate for Payer: First Health Commercial |
$76.48
|
| Rate for Payer: Humana Commercial |
$68.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.84
|
| Rate for Payer: Ohio Health Group HMO |
$60.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.96
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
PEPCID 20MG
|
Facility
|
OP
|
$80.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$61.98
|
| Rate for Payer: Anthem Medicaid |
$27.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.79
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cigna Commercial |
$66.82
|
| Rate for Payer: First Health Commercial |
$76.48
|
| Rate for Payer: Humana Commercial |
$68.42
|
| Rate for Payer: Humana KY Medicaid |
$27.68
|
| Rate for Payer: Kentucky WC Medicaid |
$27.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.84
|
| Rate for Payer: Ohio Health Group HMO |
$60.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.96
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
PEPCID (FAMOTIDINE) 200MG/20ML
|
Facility
|
OP
|
$115.79
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$111.16 |
| Rate for Payer: Aetna Commercial |
$89.16
|
| Rate for Payer: Anthem Medicaid |
$39.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$96.11
|
| Rate for Payer: First Health Commercial |
$110.00
|
| Rate for Payer: Humana Commercial |
$98.42
|
| Rate for Payer: Humana KY Medicaid |
$39.82
|
| Rate for Payer: Kentucky WC Medicaid |
$40.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.90
|
| Rate for Payer: Ohio Health Group HMO |
$86.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.89
|
| Rate for Payer: PHCS Commercial |
$111.16
|
| Rate for Payer: United Healthcare All Payer |
$101.90
|
|
|
PEPCID (FAMOTIDINE) 200MG/20ML
|
Facility
|
IP
|
$115.79
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$111.16 |
| Rate for Payer: Aetna Commercial |
$89.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$96.11
|
| Rate for Payer: First Health Commercial |
$110.00
|
| Rate for Payer: Humana Commercial |
$98.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.90
|
| Rate for Payer: Ohio Health Group HMO |
$86.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.89
|
| Rate for Payer: PHCS Commercial |
$111.16
|
| Rate for Payer: United Healthcare All Payer |
$101.90
|
|
|
PEPCID (FAMOTIDINE) 20MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60687059501
|
| Hospital Charge Code |
25001171
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
PEPCID (FAMOTIDINE) 20MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60687059501
|
| Hospital Charge Code |
25001171
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
PEPTO BISMOL TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 37000047709
|
| Hospital Charge Code |
25001172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
