|
PENIS PLASTIC SURGERY
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS 54360
|
| Hospital Charge Code |
76102966
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
PENIS PLASTIC SURGERY
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS 54360
|
| Hospital Charge Code |
76102966
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.25 |
| Max. Negotiated Rate |
$1,186.70 |
| Rate for Payer: Aetna Commercial |
$1,186.70
|
| Rate for Payer: Ambetter Exchange |
$682.36
|
| Rate for Payer: Anthem Medicaid |
$540.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$682.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$682.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$818.83
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,073.50
|
| Rate for Payer: Healthspan PPO |
$1,149.03
|
| Rate for Payer: Humana Medicaid |
$540.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$988.07
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$682.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$682.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$551.05
|
| Rate for Payer: Molina Healthcare Passport |
$540.25
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$887.07
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$545.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$682.36
|
|
|
PENTAM-300 (PENTAMID 300MG/3ML
|
Facility
|
IP
|
$594.89
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003343
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$178.47 |
| 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 |
$475.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$517.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$410.47
|
| 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
|
890
|
| Min. Negotiated Rate |
$178.47 |
| 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 |
$475.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$517.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$410.47
|
| 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 |
$3.31 |
| 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 |
$8.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.62
|
| 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 |
$3.31 |
| 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 |
$8.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.62
|
| Rate for Payer: PHCS Commercial |
$10.60
|
| Rate for Payer: United Healthcare All Payer |
$9.72
|
|
|
PEN-VEE K 500mg Tablet
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 57237004101
|
| Hospital Charge Code |
25004084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
PEN-VEE K 500mg Tablet
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 57237004101
|
| Hospital Charge Code |
25004084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| 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 |
$1.28 |
| 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 |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| 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 |
$1.28 |
| 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 |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| 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 |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| 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 |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
PEPCID 0.25mg SDV 20mg/2mL
|
Facility
|
OP
|
$63.89
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
25004594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$61.33 |
| Rate for Payer: Aetna Commercial |
$49.20
|
| Rate for Payer: Anthem Medicaid |
$21.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.83
|
| Rate for Payer: Cash Price |
$31.94
|
| Rate for Payer: Cigna Commercial |
$53.03
|
| Rate for Payer: First Health Commercial |
$60.70
|
| Rate for Payer: Humana Commercial |
$54.31
|
| Rate for Payer: Humana KY Medicaid |
$21.97
|
| Rate for Payer: Kentucky WC Medicaid |
$22.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.22
|
| Rate for Payer: Ohio Health Group HMO |
$47.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.08
|
| Rate for Payer: PHCS Commercial |
$61.33
|
| Rate for Payer: United Healthcare All Payer |
$56.22
|
|
|
PEPCID 0.25mg SDV 20mg/2mL
|
Facility
|
IP
|
$63.89
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
25004594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$61.33 |
| Rate for Payer: Aetna Commercial |
$49.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.83
|
| Rate for Payer: Cash Price |
$31.94
|
| Rate for Payer: Cigna Commercial |
$53.03
|
| Rate for Payer: First Health Commercial |
$60.70
|
| Rate for Payer: Humana Commercial |
$54.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.22
|
| Rate for Payer: Ohio Health Group HMO |
$47.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.08
|
| Rate for Payer: PHCS Commercial |
$61.33
|
| Rate for Payer: United Healthcare All Payer |
$56.22
|
|
|
PEPCID 20MG
|
Facility
|
OP
|
$80.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003346
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$24.15 |
| 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 |
$66.81
|
| Rate for Payer: First Health Commercial |
$76.47
|
| 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 |
$64.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.55
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
PEPCID 20MG
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003346
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$24.15 |
| 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 |
$66.81
|
| Rate for Payer: First Health Commercial |
$76.47
|
| 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 |
$64.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.55
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
PEPCID (FAMOTIDINE) 20MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60687059501
|
| Hospital Charge Code |
25001171
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| 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 |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
PEPTO BISMOL TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 37000047709
|
| Hospital Charge Code |
25001172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| 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: 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: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PEPTO BISMOL TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 37000047709
|
| Hospital Charge Code |
25001172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PERC BIL DRAIN PLCMT EXTERNAL
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 47533
|
| Hospital Charge Code |
76101957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$244.85 |
| Max. Negotiated Rate |
$1,022.26 |
| Rate for Payer: Ambetter Exchange |
$244.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$249.30
|
| Rate for Payer: Anthem Medicaid |
$1,002.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$244.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$244.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$293.82
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$512.74
|
| Rate for Payer: Humana Medicaid |
$1,002.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$432.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$244.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,022.26
|
| Rate for Payer: Molina Healthcare Passport |
$1,002.22
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$318.31
|
| Rate for Payer: UHCCP Medicaid |
$261.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,012.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$244.85
|
|
|
PERC BIL DRAIN PLCMT EXTERNAL
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
HCPCS 47533
|
| Hospital Charge Code |
76101957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.35 |
| Max. Negotiated Rate |
$4,565.09 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Anthem Medicaid |
$163.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,260.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$370.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,565.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,402.05
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: First Health Commercial |
$451.25
|
| Rate for Payer: Humana Commercial |
$403.75
|
| Rate for Payer: Humana KY Medicaid |
$163.35
|
| Rate for Payer: Humana Medicare Advantage |
$3,260.78
|
| Rate for Payer: Kentucky WC Medicaid |
$165.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$389.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$350.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$166.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.00
|
| Rate for Payer: Ohio Health Group HMO |
$356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.75
|
| Rate for Payer: PHCS Commercial |
$456.00
|
| Rate for Payer: United Healthcare All Payer |
$418.00
|
|
|
PERC BIL DRAIN PLCMT EXTERNAL
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
HCPCS 47533
|
| Hospital Charge Code |
76101957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.50 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$370.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: First Health Commercial |
$451.25
|
| Rate for Payer: Humana Commercial |
$403.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$389.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$350.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.00
|
| Rate for Payer: Ohio Health Group HMO |
$356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.75
|
| Rate for Payer: PHCS Commercial |
$456.00
|
| Rate for Payer: United Healthcare All Payer |
$418.00
|
|
|
PERC BIL DRAIN PLCMT EXTERNA(P
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 47533
|
| Hospital Charge Code |
761P1957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$244.85 |
| Max. Negotiated Rate |
$1,022.26 |
| Rate for Payer: Ambetter Exchange |
$244.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$249.30
|
| Rate for Payer: Anthem Medicaid |
$1,002.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$244.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$244.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$293.82
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$512.74
|
| Rate for Payer: Humana Medicaid |
$1,002.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$432.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$244.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,022.26
|
| Rate for Payer: Molina Healthcare Passport |
$1,002.22
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$318.31
|
| Rate for Payer: UHCCP Medicaid |
$261.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,012.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$244.85
|
|
|
PERC DE COR REVASC CHRO ADTL
|
Facility
|
OP
|
$14,544.00
|
|
|
Service Code
|
HCPCS C9608
|
| Hospital Charge Code |
48100091
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,363.20 |
| Max. Negotiated Rate |
$13,962.24 |
| Rate for Payer: Aetna Commercial |
$11,198.88
|
| Rate for Payer: Anthem Medicaid |
$5,001.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,344.32
|
| Rate for Payer: Cash Price |
$7,272.00
|
| Rate for Payer: Cigna Commercial |
$12,071.52
|
| Rate for Payer: First Health Commercial |
$13,816.80
|
| Rate for Payer: Humana Commercial |
$12,362.40
|
| Rate for Payer: Humana KY Medicaid |
$5,001.68
|
| Rate for Payer: Kentucky WC Medicaid |
$5,052.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,926.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,733.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,363.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,102.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,798.72
|
| Rate for Payer: Ohio Health Group HMO |
$10,908.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,635.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,653.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,035.36
|
| Rate for Payer: PHCS Commercial |
$13,962.24
|
| Rate for Payer: United Healthcare All Payer |
$12,798.72
|
|
