|
PHASE TWO RECOV PER 1/2 HR
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
71000003
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
PHENERGAN DM (PROMETH/DEX 10ML
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 70436015541
|
| Hospital Charge Code |
25001183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna Commercial |
$4.10
|
| Rate for Payer: First Health Commercial |
$4.69
|
| Rate for Payer: Humana Commercial |
$4.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.35
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.74
|
| Rate for Payer: United Healthcare All Payer |
$4.35
|
|
|
PHENERGAN DM (PROMETH/DEX 10ML
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 70436015541
|
| Hospital Charge Code |
25001183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna Commercial |
$4.10
|
| Rate for Payer: First Health Commercial |
$4.69
|
| Rate for Payer: Humana Commercial |
$4.20
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.35
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.74
|
| Rate for Payer: United Healthcare All Payer |
$4.35
|
|
|
PHENERGAN (PROMETH 12.5MG/1TAB
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
25001179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
PHENERGAN (PROMETH 12.5MG/1TAB
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
25001179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
PHENERGAN (PROMETHA 12.5MG/1EA
|
Facility
|
OP
|
$26.75
|
|
|
Service Code
|
NDC 713053612
|
| Hospital Charge Code |
25001180
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$25.68 |
| Rate for Payer: Aetna Commercial |
$20.60
|
| Rate for Payer: Anthem Medicaid |
$9.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.86
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cigna Commercial |
$22.20
|
| Rate for Payer: First Health Commercial |
$25.41
|
| Rate for Payer: Humana Commercial |
$22.74
|
| Rate for Payer: Humana KY Medicaid |
$9.20
|
| Rate for Payer: Kentucky WC Medicaid |
$9.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.54
|
| Rate for Payer: Ohio Health Group HMO |
$20.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.29
|
| Rate for Payer: PHCS Commercial |
$25.68
|
| Rate for Payer: United Healthcare All Payer |
$23.54
|
|
|
PHENERGAN (PROMETHA 12.5MG/1EA
|
Facility
|
IP
|
$26.75
|
|
|
Service Code
|
NDC 713053612
|
| Hospital Charge Code |
25001180
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$25.68 |
| Rate for Payer: Aetna Commercial |
$20.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.86
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cigna Commercial |
$22.20
|
| Rate for Payer: First Health Commercial |
$25.41
|
| Rate for Payer: Humana Commercial |
$22.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.54
|
| Rate for Payer: Ohio Health Group HMO |
$20.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.29
|
| Rate for Payer: PHCS Commercial |
$25.68
|
| Rate for Payer: United Healthcare All Payer |
$23.54
|
|
|
PHENERGAN (PROMETHAZ) 25MG/1EA
|
Facility
|
IP
|
$26.75
|
|
|
Service Code
|
HCPCS J8597
|
| Hospital Charge Code |
25001182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$25.68 |
| Rate for Payer: Aetna Commercial |
$20.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.86
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cigna Commercial |
$22.20
|
| Rate for Payer: First Health Commercial |
$25.41
|
| Rate for Payer: Humana Commercial |
$22.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.54
|
| Rate for Payer: Ohio Health Group HMO |
$20.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.29
|
| Rate for Payer: PHCS Commercial |
$25.68
|
| Rate for Payer: United Healthcare All Payer |
$23.54
|
|
|
PHENERGAN (PROMETHAZ) 25MG/1EA
|
Facility
|
OP
|
$26.75
|
|
|
Service Code
|
HCPCS J8597
|
| Hospital Charge Code |
25001182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$25.68 |
| Rate for Payer: Aetna Commercial |
$20.60
|
| Rate for Payer: Anthem Medicaid |
$9.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.86
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cigna Commercial |
$22.20
|
| Rate for Payer: First Health Commercial |
$25.41
|
| Rate for Payer: Humana Commercial |
$22.74
|
| Rate for Payer: Humana KY Medicaid |
$9.20
|
| Rate for Payer: Kentucky WC Medicaid |
$9.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.54
|
| Rate for Payer: Ohio Health Group HMO |
$20.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.29
|
| Rate for Payer: PHCS Commercial |
$25.68
|
| Rate for Payer: United Healthcare All Payer |
$23.54
|
|
|
PHENERGAN (PROMETHAZ 25MG/1TAB
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
25001181
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
|
|
PHENERGAN (PROMETHAZ 25MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
25001181
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
PHENERGAN VC (PROMETHAZIN 10ML
|
Facility
|
IP
|
$9.80
|
|
|
Service Code
|
NDC 121092616
|
| Hospital Charge Code |
25001184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.41 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.64
|
| Rate for Payer: Cash Price |
$4.90
|
| Rate for Payer: Cigna Commercial |
$8.13
|
| Rate for Payer: First Health Commercial |
$9.31
|
| Rate for Payer: Humana Commercial |
$8.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.62
|
| Rate for Payer: Ohio Health Group HMO |
$7.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$9.41
|
| Rate for Payer: United Healthcare All Payer |
$8.62
|
|
|
PHENERGAN VC (PROMETHAZIN 10ML
|
Facility
|
OP
|
$9.80
|
|
|
Service Code
|
NDC 121092616
|
| Hospital Charge Code |
25001184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.41 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Anthem Medicaid |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.64
|
| Rate for Payer: Cash Price |
$4.90
|
| Rate for Payer: Cigna Commercial |
$8.13
|
| Rate for Payer: First Health Commercial |
$9.31
|
| Rate for Payer: Humana Commercial |
$8.33
|
| Rate for Payer: Humana KY Medicaid |
$3.37
|
| Rate for Payer: Kentucky WC Medicaid |
$3.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.62
|
| Rate for Payer: Ohio Health Group HMO |
$7.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$9.41
|
| Rate for Payer: United Healthcare All Payer |
$8.62
|
|
|
PHENOBARBITAL
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
30000040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem Medicaid |
$15.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.30
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Humana KY Medicaid |
$15.30
|
| Rate for Payer: Humana Medicare Advantage |
$15.30
|
| Rate for Payer: Kentucky WC Medicaid |
$15.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.87
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
PHENOBARBITAL
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
30000040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.87
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
PHENOBARBITAL 16.2MG TABLET
|
Facility
|
OP
|
$60.42
|
|
|
Service Code
|
NDC 69367021101
|
| Hospital Charge Code |
25003351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$46.52
|
| Rate for Payer: Anthem Medicaid |
$20.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.13
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna Commercial |
$50.15
|
| Rate for Payer: First Health Commercial |
$57.40
|
| Rate for Payer: Humana Commercial |
$51.36
|
| Rate for Payer: Humana KY Medicaid |
$20.78
|
| Rate for Payer: Kentucky WC Medicaid |
$20.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.17
|
| Rate for Payer: Ohio Health Group HMO |
$45.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.73
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
PHENOBARBITAL 16.2MG TABLET
|
Facility
|
IP
|
$60.42
|
|
|
Service Code
|
NDC 69367021101
|
| Hospital Charge Code |
25003351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$46.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.13
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna Commercial |
$50.15
|
| Rate for Payer: First Health Commercial |
$57.40
|
| Rate for Payer: Humana Commercial |
$51.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.17
|
| Rate for Payer: Ohio Health Group HMO |
$45.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.73
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
IP
|
$60.54
|
|
|
Service Code
|
NDC 16571067301
|
| Hospital Charge Code |
25003352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$58.12 |
| Rate for Payer: Aetna Commercial |
$46.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.22
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cigna Commercial |
$50.25
|
| Rate for Payer: First Health Commercial |
$57.51
|
| Rate for Payer: Humana Commercial |
$51.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.28
|
| Rate for Payer: Ohio Health Group HMO |
$45.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.77
|
| Rate for Payer: PHCS Commercial |
$58.12
|
| Rate for Payer: United Healthcare All Payer |
$53.28
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
OP
|
$60.54
|
|
|
Service Code
|
NDC 16571067301
|
| Hospital Charge Code |
25003352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$58.12 |
| Rate for Payer: Aetna Commercial |
$46.62
|
| Rate for Payer: Anthem Medicaid |
$20.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.22
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cigna Commercial |
$50.25
|
| Rate for Payer: First Health Commercial |
$57.51
|
| Rate for Payer: Humana Commercial |
$51.46
|
| Rate for Payer: Humana KY Medicaid |
$20.82
|
| Rate for Payer: Kentucky WC Medicaid |
$21.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.28
|
| Rate for Payer: Ohio Health Group HMO |
$45.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.77
|
| Rate for Payer: PHCS Commercial |
$58.12
|
| Rate for Payer: United Healthcare All Payer |
$53.28
|
|
|
PHENOL
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
76102350
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.04 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$283.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$88.04
|
| Rate for Payer: Anthem Medicaid |
$99.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$386.94
|
| Rate for Payer: Healthspan PPO |
$280.49
|
| Rate for Payer: Humana Medicaid |
$99.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$213.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.93
|
| Rate for Payer: Molina Healthcare Passport |
$99.93
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$92.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.93
|
|
|
PHENOL
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
76102350
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
PHENOL
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
76102350
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$1,103.49 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
PHENOL EZ 89% SWAB
|
Facility
|
OP
|
$12.55
|
|
|
Service Code
|
NDC 884629730
|
| Hospital Charge Code |
25003742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Aetna Commercial |
$9.66
|
| Rate for Payer: Anthem Medicaid |
$4.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.79
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cigna Commercial |
$10.42
|
| Rate for Payer: First Health Commercial |
$11.92
|
| Rate for Payer: Humana Commercial |
$10.67
|
| Rate for Payer: Humana KY Medicaid |
$4.32
|
| Rate for Payer: Kentucky WC Medicaid |
$4.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.04
|
| Rate for Payer: Ohio Health Group HMO |
$9.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.89
|
| Rate for Payer: PHCS Commercial |
$12.05
|
| Rate for Payer: United Healthcare All Payer |
$11.04
|
|
|
PHENOL EZ 89% SWAB
|
Facility
|
IP
|
$12.55
|
|
|
Service Code
|
NDC 884629730
|
| Hospital Charge Code |
25003742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Aetna Commercial |
$9.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.79
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cigna Commercial |
$10.42
|
| Rate for Payer: First Health Commercial |
$11.92
|
| Rate for Payer: Humana Commercial |
$10.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.04
|
| Rate for Payer: Ohio Health Group HMO |
$9.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.89
|
| Rate for Payer: PHCS Commercial |
$12.05
|
| Rate for Payer: United Healthcare All Payer |
$11.04
|
|
|
PHENOL(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
761P2350
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.04 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$283.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$88.04
|
| Rate for Payer: Anthem Medicaid |
$99.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$386.94
|
| Rate for Payer: Healthspan PPO |
$280.49
|
| Rate for Payer: Humana Medicaid |
$99.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$213.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.93
|
| Rate for Payer: Molina Healthcare Passport |
$99.93
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$92.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.93
|
|
