|
PROTEGE STENT 7*15 6FR
|
Facility
|
IP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE STENT 7*80
|
Facility
|
IP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE STENT 7*80
|
Facility
|
OP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem Medicaid |
$1,689.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Humana KY Medicaid |
$1,689.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEINSERUMTOTAL
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 84155
|
| Hospital Charge Code |
30000492
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem Medicaid |
$3.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.67
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Humana KY Medicaid |
$3.67
|
| Rate for Payer: Humana Medicare Advantage |
$3.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
PROTEINSERUMTOTAL
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 84155
|
| Hospital Charge Code |
30000492
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
PROTEUS SP ATPD GENE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
PROTEUS SP ATPD GENE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$20.05
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$20.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
PROTHROMBIN-INR
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS 85610
|
| Hospital Charge Code |
30000618
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem Medicaid |
$4.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.29
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Humana KY Medicaid |
$4.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.29
|
| Rate for Payer: Kentucky WC Medicaid |
$4.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.33
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
PROTHROMBIN-INR
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS 85610
|
| Hospital Charge Code |
30000618
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$43.00
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$5.37
|
| Rate for Payer: Healthspan PPO |
$4.12
|
| Rate for Payer: Multiplan PHCS |
$25.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.10
|
| Rate for Payer: UHCCP Medicaid |
$15.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2.57
|
|
|
PROTHROMBIN-INR
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS 85610
|
| Hospital Charge Code |
30000618
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34.53
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.33
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
PROTHROMBIN TIME;
|
Facility
|
OP
|
$6.01
|
|
|
Service Code
|
CPT 85610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Anthem Medicaid |
$4.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.29
|
| Rate for Payer: Humana KY Medicaid |
$4.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.29
|
| Rate for Payer: Kentucky WC Medicaid |
$4.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.38
|
|
|
PROTONIX 20MG TABLET
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 60687072501
|
| Hospital Charge Code |
25001260
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PROTONIX 20MG TABLET
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 60687072501
|
| Hospital Charge Code |
25001260
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PROTONIX (GEN) 40MG IVP
|
Facility
|
IP
|
$112.08
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
25003391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.60 |
| Rate for Payer: Aetna Commercial |
$86.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.42
|
| Rate for Payer: Cash Price |
$56.04
|
| Rate for Payer: Cigna Commercial |
$93.03
|
| Rate for Payer: First Health Commercial |
$106.48
|
| Rate for Payer: Humana Commercial |
$95.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.63
|
| Rate for Payer: Ohio Health Group HMO |
$84.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.74
|
| Rate for Payer: PHCS Commercial |
$107.60
|
| Rate for Payer: United Healthcare All Payer |
$98.63
|
|
|
PROTONIX (GEN) 40MG IVP
|
Facility
|
OP
|
$112.08
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
25003391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.60 |
| Rate for Payer: Aetna Commercial |
$86.30
|
| Rate for Payer: Anthem Medicaid |
$38.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.42
|
| Rate for Payer: Cash Price |
$56.04
|
| Rate for Payer: Cigna Commercial |
$93.03
|
| Rate for Payer: First Health Commercial |
$106.48
|
| Rate for Payer: Humana Commercial |
$95.27
|
| Rate for Payer: Humana KY Medicaid |
$38.54
|
| Rate for Payer: Kentucky WC Medicaid |
$38.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.63
|
| Rate for Payer: Ohio Health Group HMO |
$84.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.74
|
| Rate for Payer: PHCS Commercial |
$107.60
|
| Rate for Payer: United Healthcare All Payer |
$98.63
|
|
|
PROTONIX (PANTOPRAZOLE) 40MG
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.82
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
PROTONIX (PANTOPRAZOLE) 40MG
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$23.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.82
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$23.73
|
| Rate for Payer: Kentucky WC Medicaid |
$23.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
PROTONIX(PANTOPRAZO SOD)40MG T
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 60687073601
|
| Hospital Charge Code |
25001261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
PROTONIX(PANTOPRAZO SOD)40MG T
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 60687073601
|
| Hospital Charge Code |
25001261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
PROTOPAMPRALIDOXIMECHLORIDE1GM
|
Facility
|
IP
|
$355.70
|
|
|
Service Code
|
HCPCS J2730
|
| Hospital Charge Code |
25002333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.24 |
| Max. Negotiated Rate |
$341.47 |
| Rate for Payer: Aetna Commercial |
$273.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.45
|
| Rate for Payer: Cash Price |
$177.85
|
| Rate for Payer: Cigna Commercial |
$295.23
|
| Rate for Payer: First Health Commercial |
$337.92
|
| Rate for Payer: Humana Commercial |
$302.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$262.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$313.02
|
| Rate for Payer: Ohio Health Group HMO |
$266.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.27
|
| Rate for Payer: PHCS Commercial |
$341.47
|
| Rate for Payer: United Healthcare All Payer |
$313.02
|
|
|
PROTOPAMPRALIDOXIMECHLORIDE1GM
|
Facility
|
OP
|
$355.70
|
|
|
Service Code
|
HCPCS J2730
|
| Hospital Charge Code |
25002333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.24 |
| Max. Negotiated Rate |
$341.47 |
| Rate for Payer: Aetna Commercial |
$273.89
|
| Rate for Payer: Anthem Medicaid |
$122.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.45
|
| Rate for Payer: Cash Price |
$177.85
|
| Rate for Payer: Cigna Commercial |
$295.23
|
| Rate for Payer: First Health Commercial |
$337.92
|
| Rate for Payer: Humana Commercial |
$302.34
|
| Rate for Payer: Humana KY Medicaid |
$122.33
|
| Rate for Payer: Kentucky WC Medicaid |
$123.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$262.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$313.02
|
| Rate for Payer: Ohio Health Group HMO |
$266.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.27
|
| Rate for Payer: PHCS Commercial |
$341.47
|
| Rate for Payer: United Healthcare All Payer |
$313.02
|
|
|
PROTOPIC(TACROLIMUS)ONT.1%30GR
|
Facility
|
OP
|
$11.17
|
|
|
Service Code
|
NDC 68462053435
|
| Hospital Charge Code |
25001262
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$10.72 |
| Rate for Payer: Aetna Commercial |
$8.60
|
| Rate for Payer: Anthem Medicaid |
$3.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.71
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.27
|
| Rate for Payer: First Health Commercial |
$10.61
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Humana KY Medicaid |
$3.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.83
|
| Rate for Payer: Ohio Health Group HMO |
$8.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$10.72
|
| Rate for Payer: United Healthcare All Payer |
$9.83
|
|
|
PROTOPIC(TACROLIMUS)ONT.1%30GR
|
Facility
|
IP
|
$11.17
|
|
|
Service Code
|
NDC 68462053435
|
| Hospital Charge Code |
25001262
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$10.72 |
| Rate for Payer: Aetna Commercial |
$8.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.71
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.27
|
| Rate for Payer: First Health Commercial |
$10.61
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.83
|
| Rate for Payer: Ohio Health Group HMO |
$8.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$10.72
|
| Rate for Payer: United Healthcare All Payer |
$9.83
|
|
|
PROTRUSIO CAGES 48*45 L
|
Facility
|
IP
|
$11,018.66
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,432.43 |
| Max. Negotiated Rate |
$10,577.91 |
| Rate for Payer: Aetna Commercial |
$8,484.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,594.55
|
| Rate for Payer: Cash Price |
$5,509.33
|
| Rate for Payer: Cigna Commercial |
$9,145.49
|
| Rate for Payer: First Health Commercial |
$10,467.73
|
| Rate for Payer: Humana Commercial |
$9,365.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,035.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,131.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,305.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,696.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,264.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,203.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,432.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,415.78
|
| Rate for Payer: PHCS Commercial |
$10,577.91
|
| Rate for Payer: United Healthcare All Payer |
$9,696.42
|
|
|
PROTRUSIO CAGES 48*45 L
|
Facility
|
OP
|
$11,018.66
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,432.43 |
| Max. Negotiated Rate |
$10,577.91 |
| Rate for Payer: Aetna Commercial |
$8,484.37
|
| Rate for Payer: Anthem Medicaid |
$3,789.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,594.55
|
| Rate for Payer: Cash Price |
$5,509.33
|
| Rate for Payer: Cigna Commercial |
$9,145.49
|
| Rate for Payer: First Health Commercial |
$10,467.73
|
| Rate for Payer: Humana Commercial |
$9,365.86
|
| Rate for Payer: Humana KY Medicaid |
$3,789.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,827.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,035.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,131.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,305.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,865.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,696.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,264.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,203.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,432.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,415.78
|
| Rate for Payer: PHCS Commercial |
$10,577.91
|
| Rate for Payer: United Healthcare All Payer |
$9,696.42
|
|
