|
PROLININ 2.5MG/1TAB
|
Facility
|
OP
|
$10.32
|
|
|
Service Code
|
NDC 527178901
|
| Hospital Charge Code |
25001247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$9.91 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem Medicaid |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.80
|
| Rate for Payer: Humana Commercial |
$8.77
|
| Rate for Payer: Humana KY Medicaid |
$3.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.08
|
| Rate for Payer: Ohio Health Group HMO |
$7.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Payer |
$9.08
|
|
|
PROLININ 2.5MG/1TAB
|
Facility
|
IP
|
$10.32
|
|
|
Service Code
|
NDC 527178901
|
| Hospital Charge Code |
25001247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$9.91 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.80
|
| Rate for Payer: Humana Commercial |
$8.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.08
|
| Rate for Payer: Ohio Health Group HMO |
$7.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Payer |
$9.08
|
|
|
PROLIXIN 10MG EQUIVALENT TAB
|
Facility
|
OP
|
$11.96
|
|
|
Service Code
|
NDC 527179101
|
| Hospital Charge Code |
25001250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Humana Commercial |
$10.17
|
| Rate for Payer: Humana KY Medicaid |
$4.11
|
| Rate for Payer: Kentucky WC Medicaid |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.52
|
| Rate for Payer: Ohio Health Group HMO |
$8.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.71
|
| Rate for Payer: PHCS Commercial |
$11.48
|
| Rate for Payer: United Healthcare All Payer |
$10.52
|
| Rate for Payer: Aetna Commercial |
$9.21
|
| Rate for Payer: Anthem Medicaid |
$4.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.33
|
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: Cigna Commercial |
$9.93
|
| Rate for Payer: First Health Commercial |
$11.36
|
|
|
PROLIXIN 10MG EQUIVALENT TAB
|
Facility
|
IP
|
$11.96
|
|
|
Service Code
|
NDC 527179101
|
| Hospital Charge Code |
25001250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$9.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.33
|
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: Cigna Commercial |
$9.93
|
| Rate for Payer: First Health Commercial |
$11.36
|
| Rate for Payer: Humana Commercial |
$10.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.52
|
| Rate for Payer: Ohio Health Group HMO |
$8.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.71
|
| Rate for Payer: PHCS Commercial |
$11.48
|
| Rate for Payer: United Healthcare All Payer |
$10.52
|
|
|
PROLIXINDECANOAT25MG/ML 5 ML V
|
Facility
|
OP
|
$549.00
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
25002324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.37 |
| Max. Negotiated Rate |
$527.04 |
| Rate for Payer: Aetna Commercial |
$422.73
|
| Rate for Payer: Anthem Medicaid |
$188.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$428.22
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$455.67
|
| Rate for Payer: First Health Commercial |
$521.55
|
| Rate for Payer: Humana Commercial |
$466.65
|
| Rate for Payer: Humana KY Medicaid |
$188.80
|
| Rate for Payer: Kentucky WC Medicaid |
$190.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$450.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$483.12
|
| Rate for Payer: Ohio Health Group HMO |
$411.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.19
|
| Rate for Payer: PHCS Commercial |
$527.04
|
| Rate for Payer: United Healthcare All Payer |
$483.12
|
|
|
PROLIXINDECANOAT25MG/ML 5 ML V
|
Facility
|
IP
|
$549.00
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
25002324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.37 |
| Max. Negotiated Rate |
$527.04 |
| Rate for Payer: Aetna Commercial |
$422.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$428.22
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$455.67
|
| Rate for Payer: First Health Commercial |
$521.55
|
| Rate for Payer: Humana Commercial |
$466.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$450.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$483.12
|
| Rate for Payer: Ohio Health Group HMO |
$411.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.19
|
| Rate for Payer: PHCS Commercial |
$527.04
|
| Rate for Payer: United Healthcare All Payer |
$483.12
|
|
|
PROLIXIN(FLUPHENA)2.5MG/5MLELX
|
Facility
|
OP
|
$10.67
|
|
|
Service Code
|
NDC 121065402
|
| Hospital Charge Code |
25001251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem Medicaid |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.32
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.14
|
| Rate for Payer: Humana Commercial |
$9.07
|
| Rate for Payer: Humana KY Medicaid |
$3.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.39
|
| Rate for Payer: Ohio Health Group HMO |
$8.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$10.24
|
| Rate for Payer: United Healthcare All Payer |
$9.39
|
|
|
PROLIXIN(FLUPHENA)2.5MG/5MLELX
|
Facility
|
IP
|
$10.67
|
|
|
Service Code
|
NDC 121065402
|
| Hospital Charge Code |
25001251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.32
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.14
|
| Rate for Payer: Humana Commercial |
$9.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.39
|
| Rate for Payer: Ohio Health Group HMO |
$8.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$10.24
|
| Rate for Payer: United Healthcare All Payer |
$9.39
|
|
|
PROLIXIN (FLUPHENAZIN 1MG/1TAB
|
Facility
|
IP
|
$4.89
|
|
|
Service Code
|
NDC 69238167801
|
| Hospital Charge Code |
25001248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.06
|
| Rate for Payer: First Health Commercial |
$4.65
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.30
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.69
|
| Rate for Payer: United Healthcare All Payer |
$4.30
|
|
|
PROLIXIN (FLUPHENAZIN 1MG/1TAB
|
Facility
|
OP
|
$4.89
|
|
|
Service Code
|
NDC 69238167801
|
| Hospital Charge Code |
25001248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.06
|
| Rate for Payer: First Health Commercial |
$4.65
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.30
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.69
|
| Rate for Payer: United Healthcare All Payer |
$4.30
|
|
|
PROLIXIN(FLUPHENAZIN 25MG/10ML
|
Facility
|
OP
|
$620.07
|
|
|
Service Code
|
NDC 63323028110
|
| Hospital Charge Code |
25003387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.61 |
| Max. Negotiated Rate |
$595.27 |
| Rate for Payer: Aetna Commercial |
$477.45
|
| Rate for Payer: Anthem Medicaid |
$213.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.65
|
| Rate for Payer: Cash Price |
$310.04
|
| Rate for Payer: Cigna Commercial |
$514.66
|
| Rate for Payer: First Health Commercial |
$589.07
|
| Rate for Payer: Humana Commercial |
$527.06
|
| Rate for Payer: Humana KY Medicaid |
$213.24
|
| Rate for Payer: Kentucky WC Medicaid |
$215.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.66
|
| Rate for Payer: Ohio Health Group HMO |
$465.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.22
|
| Rate for Payer: PHCS Commercial |
$595.27
|
| Rate for Payer: United Healthcare All Payer |
$545.66
|
|
|
PROLIXIN(FLUPHENAZIN 25MG/10ML
|
Facility
|
IP
|
$620.07
|
|
|
Service Code
|
NDC 63323028110
|
| Hospital Charge Code |
25003387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.61 |
| Max. Negotiated Rate |
$595.27 |
| Rate for Payer: Aetna Commercial |
$477.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.65
|
| Rate for Payer: Cash Price |
$310.04
|
| Rate for Payer: Cigna Commercial |
$514.66
|
| Rate for Payer: First Health Commercial |
$589.07
|
| Rate for Payer: Humana Commercial |
$527.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.66
|
| Rate for Payer: Ohio Health Group HMO |
$465.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.22
|
| Rate for Payer: PHCS Commercial |
$595.27
|
| Rate for Payer: United Healthcare All Payer |
$545.66
|
|
|
PROLIXIN (FLUPHENAZIN 5MG/1TAB
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 69238168001
|
| Hospital Charge Code |
25001249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Anthem Medicaid |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.98
|
| Rate for Payer: Humana Commercial |
$8.03
|
| Rate for Payer: Humana KY Medicaid |
$3.25
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.32
|
| Rate for Payer: Ohio Health Group HMO |
$7.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$9.07
|
| Rate for Payer: United Healthcare All Payer |
$8.32
|
|
|
PROLIXIN (FLUPHENAZIN 5MG/1TAB
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 69238168001
|
| Hospital Charge Code |
25001249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.98
|
| Rate for Payer: Humana Commercial |
$8.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.32
|
| Rate for Payer: Ohio Health Group HMO |
$7.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$9.07
|
| Rate for Payer: United Healthcare All Payer |
$8.32
|
|
|
PROLNG CLIN STAFF SVC 1ST HR
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 99415
|
| Hospital Charge Code |
51000350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem Medicaid |
$13.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Humana KY Medicaid |
$13.07
|
| Rate for Payer: Kentucky WC Medicaid |
$13.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.78
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
|
PROLNG CLIN STAFF SVC 1ST HR
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
HCPCS 99415
|
| Hospital Charge Code |
51000350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.45 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Anthem Medicaid |
$6.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.00
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$13.76
|
| Rate for Payer: Humana Medicaid |
$6.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$6.58
|
| Rate for Payer: Molina Healthcare Passport |
$6.45
|
| Rate for Payer: Multiplan PHCS |
$22.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$26.60
|
| Rate for Payer: UHCCP Medicaid |
$13.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$6.51
|
|
|
PROLNG CLIN STAFF SVC 1ST HR
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS 99415
|
| Hospital Charge Code |
51000350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.78
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
|
PROLNG CLIN STAFF SVC EA ADD
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS 99416
|
| Hospital Charge Code |
51000351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.75
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
PROLNG CLIN STAFF SVC EA ADD
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS 99416
|
| Hospital Charge Code |
51000351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem Medicaid |
$8.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Humana KY Medicaid |
$8.60
|
| Rate for Payer: Kentucky WC Medicaid |
$8.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.75
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
PROLNG CLIN STAFF SVC EA ADD
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 99416
|
| Hospital Charge Code |
51000351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Anthem Medicaid |
$0.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$25.00
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: Humana Medicaid |
$0.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$0.50
|
| Rate for Payer: Molina Healthcare Passport |
$0.49
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.50
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$0.49
|
|
|
PROLNG IP/OBS E/M EA 15 MIN
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 99418
|
| Hospital Charge Code |
51000339
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Anthem Medicaid |
$33.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Humana Medicaid |
$33.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.75
|
| Rate for Payer: Molina Healthcare Passport |
$33.09
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.42
|
|
|
PROLNG IP/OBS E/M EA 15 MIN(P
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 99418
|
| Hospital Charge Code |
510P0339
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Anthem Medicaid |
$33.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Humana Medicaid |
$33.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.75
|
| Rate for Payer: Molina Healthcare Passport |
$33.09
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.42
|
|
|
PROLNG OFF/OP E/M EA 15 MIN
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
51000309
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$22.87
|
| Rate for Payer: Anthem Medicaid |
$25.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$25.00
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Humana Medicaid |
$25.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.25
|
| Rate for Payer: Molina Healthcare Passport |
$25.74
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.50
|
| Rate for Payer: UHCCP Medicaid |
$24.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.00
|
|
|
PROLNG OP E/M EACH 15 MIN
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
51000338
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem Medicaid |
$42.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Humana KY Medicaid |
$42.99
|
| Rate for Payer: Kentucky WC Medicaid |
$43.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.75
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
PROLNG OP E/M EACH 15 MIN
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
51000338
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$22.87
|
| Rate for Payer: Anthem Medicaid |
$25.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Humana Medicaid |
$25.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.25
|
| Rate for Payer: Molina Healthcare Passport |
$25.74
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$24.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.00
|
|
