|
PHAR STRESS/DOBUTAMiNE
|
Facility
|
OP
|
$1,242.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200005
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$287.73 |
| Max. Negotiated Rate |
$1,192.32 |
| Rate for Payer: Aetna Commercial |
$956.34
|
| Rate for Payer: Anthem Medicaid |
$427.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$968.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$621.00
|
| Rate for Payer: Cash Price |
$621.00
|
| Rate for Payer: Cigna Commercial |
$1,030.86
|
| Rate for Payer: First Health Commercial |
$1,179.90
|
| Rate for Payer: Humana Commercial |
$1,055.70
|
| Rate for Payer: Humana KY Medicaid |
$427.12
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$431.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,018.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$916.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$435.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,092.96
|
| Rate for Payer: Ohio Health Group HMO |
$931.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$993.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,080.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$856.98
|
| Rate for Payer: PHCS Commercial |
$1,192.32
|
| Rate for Payer: United Healthcare All Payer |
$1,092.96
|
|
|
PHAR STRESS/DOBUTAMiNE
|
Facility
|
IP
|
$1,242.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200005
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$372.60 |
| Max. Negotiated Rate |
$1,192.32 |
| Rate for Payer: Aetna Commercial |
$956.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$968.76
|
| Rate for Payer: Cash Price |
$621.00
|
| Rate for Payer: Cigna Commercial |
$1,030.86
|
| Rate for Payer: First Health Commercial |
$1,179.90
|
| Rate for Payer: Humana Commercial |
$1,055.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,018.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$916.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$372.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,092.96
|
| Rate for Payer: Ohio Health Group HMO |
$931.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$993.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,080.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$856.98
|
| Rate for Payer: PHCS Commercial |
$1,192.32
|
| Rate for Payer: United Healthcare All Payer |
$1,092.96
|
|
|
PHASE ONE REC 1ST 1/2HR
|
Facility
|
OP
|
$1,862.00
|
|
| Hospital Charge Code |
71000002
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$558.60 |
| Max. Negotiated Rate |
$1,787.52 |
| Rate for Payer: Aetna Commercial |
$1,433.74
|
| Rate for Payer: Anthem Medicaid |
$640.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,452.36
|
| Rate for Payer: Cash Price |
$931.00
|
| Rate for Payer: Cigna Commercial |
$1,545.46
|
| Rate for Payer: First Health Commercial |
$1,768.90
|
| Rate for Payer: Humana Commercial |
$1,582.70
|
| Rate for Payer: Humana KY Medicaid |
$640.34
|
| Rate for Payer: Kentucky WC Medicaid |
$646.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,526.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,374.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$558.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$653.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,638.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,489.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,619.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,284.78
|
| Rate for Payer: PHCS Commercial |
$1,787.52
|
| Rate for Payer: United Healthcare All Payer |
$1,638.56
|
|
|
PHASE ONE REC 1ST 1/2HR
|
Facility
|
IP
|
$1,862.00
|
|
| Hospital Charge Code |
71000002
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$558.60 |
| Max. Negotiated Rate |
$1,787.52 |
| Rate for Payer: Aetna Commercial |
$1,433.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,452.36
|
| Rate for Payer: Cash Price |
$931.00
|
| Rate for Payer: Cigna Commercial |
$1,545.46
|
| Rate for Payer: First Health Commercial |
$1,768.90
|
| Rate for Payer: Humana Commercial |
$1,582.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,526.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,374.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$558.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,638.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,489.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,619.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,284.78
|
| Rate for Payer: PHCS Commercial |
$1,787.52
|
| Rate for Payer: United Healthcare All Payer |
$1,638.56
|
|
|
PHASE ONE REC EA ADDL 1/2HR
|
Facility
|
OP
|
$931.00
|
|
| Hospital Charge Code |
71000001
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$279.30 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem Medicaid |
$320.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Humana KY Medicaid |
$320.17
|
| Rate for Payer: Kentucky WC Medicaid |
$323.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$744.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$809.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.39
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
PHASE ONE REC EA ADDL 1/2HR
|
Facility
|
IP
|
$931.00
|
|
| Hospital Charge Code |
71000001
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$279.30 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$744.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$809.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.39
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
PHASE TWO RECOV PER 1/2 HR
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
71000003
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.86
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.53
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
PHASE TWO RECOV PER 1/2 HR
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
71000003
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.86
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Humana KY Medicaid |
$12.72
|
| Rate for Payer: Kentucky WC Medicaid |
$12.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.53
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
PHENERGAN DM (PROMETH/DEX 10ML
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 70436015541
|
| Hospital Charge Code |
25001183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$4.74
|
| Rate for Payer: United Healthcare All Payer |
$4.35
|
|
|
PHENERGAN DM (PROMETH/DEX 10ML
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 70436015541
|
| Hospital Charge Code |
25001183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| 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 |
$1.40 |
| 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 |
$3.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.21
|
| 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 |
$1.40 |
| 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 |
$3.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.21
|
| 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 |
$8.03 |
| 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 |
$21.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.03
|
| 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 |
$21.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.46
|
| 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 |
$8.03 |
| 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 |
$21.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.03
|
| 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 |
$21.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.46
|
| 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 |
$8.03 |
| 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 |
$21.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.03
|
| 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 |
$21.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.46
|
| 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 |
$8.03 |
| 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 |
$21.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.03
|
| 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 |
$21.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.46
|
| 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 |
$1.38 |
| Max. Negotiated Rate |
$4.43 |
| 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
|
| 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 |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
PHENERGAN (PROMETHAZ 25MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
25001181
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| 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 |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| 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 |
$2.94 |
| 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 |
$7.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.76
|
| 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 |
$2.94 |
| 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 |
$7.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.76
|
| Rate for Payer: PHCS Commercial |
$9.41
|
| Rate for Payer: United Healthcare All Payer |
$8.62
|
|
|
PHENOBARBITAL
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
30000040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem Medicaid |
$15.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.30
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| 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 |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.89
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
PHENOBARBITAL
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
30000040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.04
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.89
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
PHENOBARBITAL 16.2MG TABLET
|
Facility
|
IP
|
$60.42
|
|
|
Service Code
|
NDC 69367021101
|
| Hospital Charge Code |
25003351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.13 |
| 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 |
$45.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.69
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
PHENOBARBITAL 16.2MG TABLET
|
Facility
|
OP
|
$60.42
|
|
|
Service Code
|
NDC 69367021101
|
| Hospital Charge Code |
25003351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.13 |
| 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 |
$45.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.69
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
IP
|
$60.15
|
|
|
Service Code
|
NDC 16571067301
|
| Hospital Charge Code |
25003352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.92
|
| Rate for Payer: First Health Commercial |
$57.14
|
| Rate for Payer: Humana Commercial |
$51.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.93
|
| Rate for Payer: Ohio Health Group HMO |
$45.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.50
|
| Rate for Payer: PHCS Commercial |
$57.74
|
| Rate for Payer: United Healthcare All Payer |
$52.93
|
|
