|
PROTRUSIO CAGES 72*69 R
|
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
|
|
|
PROVACHOL 10MG TABLET
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 93077198
|
| Hospital Charge Code |
25001263
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| 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 |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
| Rate for Payer: Aetna Commercial |
$3.44
|
|
|
PROVACHOL 10MG TABLET
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 93077198
|
| Hospital Charge Code |
25001263
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| 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 |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
PROVAYBLUE 0.5% 10ML AMPUL
|
Facility
|
OP
|
$840.43
|
|
|
Service Code
|
NDC 517037401
|
| Hospital Charge Code |
25003392
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.26 |
| Max. Negotiated Rate |
$806.81 |
| Rate for Payer: Aetna Commercial |
$647.13
|
| Rate for Payer: Anthem Medicaid |
$289.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$655.54
|
| Rate for Payer: Cash Price |
$420.21
|
| Rate for Payer: Cigna Commercial |
$697.56
|
| Rate for Payer: First Health Commercial |
$798.41
|
| Rate for Payer: Humana Commercial |
$714.37
|
| Rate for Payer: Humana KY Medicaid |
$289.02
|
| Rate for Payer: Kentucky WC Medicaid |
$291.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$689.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$620.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$294.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$739.58
|
| Rate for Payer: Ohio Health Group HMO |
$630.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$260.53
|
| Rate for Payer: PHCS Commercial |
$806.81
|
| Rate for Payer: United Healthcare All Payer |
$739.58
|
|
|
PROVAYBLUE 0.5% 10ML AMPUL
|
Facility
|
IP
|
$840.43
|
|
|
Service Code
|
NDC 517037401
|
| Hospital Charge Code |
25003392
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.26 |
| Max. Negotiated Rate |
$806.81 |
| Rate for Payer: Aetna Commercial |
$647.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$655.54
|
| Rate for Payer: Cash Price |
$420.21
|
| Rate for Payer: Cigna Commercial |
$697.56
|
| Rate for Payer: First Health Commercial |
$798.41
|
| Rate for Payer: Humana Commercial |
$714.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$689.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$620.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$739.58
|
| Rate for Payer: Ohio Health Group HMO |
$630.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$260.53
|
| Rate for Payer: PHCS Commercial |
$806.81
|
| Rate for Payer: United Healthcare All Payer |
$739.58
|
|
|
PROVENGE 50 MM/250 PER INFSN
|
Facility
|
IP
|
$62,740.52
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
25002716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,156.27 |
| Max. Negotiated Rate |
$60,230.90 |
| Rate for Payer: Aetna Commercial |
$48,310.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48,937.61
|
| Rate for Payer: Cash Price |
$31,370.26
|
| Rate for Payer: Cigna Commercial |
$52,074.63
|
| Rate for Payer: First Health Commercial |
$59,603.49
|
| Rate for Payer: Humana Commercial |
$53,329.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51,447.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,302.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,822.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,211.66
|
| Rate for Payer: Ohio Health Group HMO |
$47,055.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,548.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,156.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,449.56
|
| Rate for Payer: PHCS Commercial |
$60,230.90
|
| Rate for Payer: United Healthcare All Payer |
$55,211.66
|
|
|
PROVENGE 50 MM/250 PER INFSN
|
Facility
|
OP
|
$62,740.52
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
25002716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,156.27 |
| Max. Negotiated Rate |
$74,797.32 |
| Rate for Payer: Aetna Commercial |
$48,310.20
|
| Rate for Payer: Anthem Medicaid |
$21,576.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$53,426.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48,937.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74,797.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$72,125.99
|
| Rate for Payer: Cash Price |
$31,370.26
|
| Rate for Payer: Cash Price |
$31,370.26
|
| Rate for Payer: Cigna Commercial |
$52,074.63
|
| Rate for Payer: First Health Commercial |
$59,603.49
|
| Rate for Payer: Humana Commercial |
$53,329.44
|
| Rate for Payer: Humana KY Medicaid |
$21,576.46
|
| Rate for Payer: Humana Medicare Advantage |
$53,426.66
|
| Rate for Payer: Kentucky WC Medicaid |
$21,796.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51,447.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,302.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64,111.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,009.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,211.66
|
| Rate for Payer: Ohio Health Group HMO |
$47,055.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,548.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,156.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,449.56
|
| Rate for Payer: PHCS Commercial |
$60,230.90
|
| Rate for Payer: United Healthcare All Payer |
$55,211.66
|
|
|
PROVENTIL(ALBUTEROL) 2 2MG/5ML
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 472082516
|
| Hospital Charge Code |
25001265
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| 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 |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PROVENTIL(ALBUTEROL) 2 2MG/5ML
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 472082516
|
| Hospital Charge Code |
25001265
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| 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 |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PROVENTIL (ALBUTEROL) 2MG/1TAB
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 70710106101
|
| Hospital Charge Code |
25001264
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
PROVENTIL (ALBUTEROL) 2MG/1TAB
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 70710106101
|
| Hospital Charge Code |
25001264
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
PROVENTILHFA 200puff/6.7gm MDI
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
NDC 60687066291
|
| Hospital Charge Code |
25004039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$168.96 |
| Rate for Payer: Aetna Commercial |
$135.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$137.28
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$146.08
|
| Rate for Payer: First Health Commercial |
$167.20
|
| Rate for Payer: Humana Commercial |
$149.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$144.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.88
|
| Rate for Payer: Ohio Health Group HMO |
$132.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.56
|
| Rate for Payer: PHCS Commercial |
$168.96
|
| Rate for Payer: United Healthcare All Payer |
$154.88
|
|
|
PROVENTILHFA 200puff/6.7gm MDI
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
NDC 60687066291
|
| Hospital Charge Code |
25004039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$168.96 |
| Rate for Payer: Aetna Commercial |
$135.52
|
| Rate for Payer: Anthem Medicaid |
$60.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$137.28
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$146.08
|
| Rate for Payer: First Health Commercial |
$167.20
|
| Rate for Payer: Humana Commercial |
$149.60
|
| Rate for Payer: Humana KY Medicaid |
$60.53
|
| Rate for Payer: Kentucky WC Medicaid |
$61.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$144.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$61.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.88
|
| Rate for Payer: Ohio Health Group HMO |
$132.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.56
|
| Rate for Payer: PHCS Commercial |
$168.96
|
| Rate for Payer: United Healthcare All Payer |
$154.88
|
|
|
PROVERA(MEDROXYPROG 2.5MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 59762005501
|
| Hospital Charge Code |
25001267
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PROVERA(MEDROXYPROG 2.5MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 59762005501
|
| Hospital Charge Code |
25001267
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PROVIGIL (MODAFINIL)100 MG TAB
|
Facility
|
OP
|
$60.97
|
|
|
Service Code
|
NDC 60505252603
|
| Hospital Charge Code |
25001268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$58.53 |
| Rate for Payer: Aetna Commercial |
$46.95
|
| Rate for Payer: Anthem Medicaid |
$20.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.56
|
| Rate for Payer: Cash Price |
$30.48
|
| Rate for Payer: Cigna Commercial |
$50.61
|
| Rate for Payer: First Health Commercial |
$57.92
|
| Rate for Payer: Humana Commercial |
$51.82
|
| Rate for Payer: Humana KY Medicaid |
$20.97
|
| Rate for Payer: Kentucky WC Medicaid |
$21.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.65
|
| Rate for Payer: Ohio Health Group HMO |
$45.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.90
|
| Rate for Payer: PHCS Commercial |
$58.53
|
| Rate for Payer: United Healthcare All Payer |
$53.65
|
|
|
PROVIGIL (MODAFINIL)100 MG TAB
|
Facility
|
IP
|
$60.97
|
|
|
Service Code
|
NDC 60505252603
|
| Hospital Charge Code |
25001268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$58.53 |
| Rate for Payer: Aetna Commercial |
$46.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.56
|
| Rate for Payer: Cash Price |
$30.48
|
| Rate for Payer: Cigna Commercial |
$50.61
|
| Rate for Payer: First Health Commercial |
$57.92
|
| Rate for Payer: Humana Commercial |
$51.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.65
|
| Rate for Payer: Ohio Health Group HMO |
$45.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.90
|
| Rate for Payer: PHCS Commercial |
$58.53
|
| Rate for Payer: United Healthcare All Payer |
$53.65
|
|
|
PROVISC(SOD.HYALUR 10MG/.85ML
|
Facility
|
IP
|
$607.72
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
25003393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.00 |
| Max. Negotiated Rate |
$583.41 |
| Rate for Payer: Aetna Commercial |
$467.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$474.02
|
| Rate for Payer: Cash Price |
$303.86
|
| Rate for Payer: Cigna Commercial |
$504.41
|
| Rate for Payer: First Health Commercial |
$577.33
|
| Rate for Payer: Humana Commercial |
$516.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$498.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$534.79
|
| Rate for Payer: Ohio Health Group HMO |
$455.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$188.39
|
| Rate for Payer: PHCS Commercial |
$583.41
|
| Rate for Payer: United Healthcare All Payer |
$534.79
|
|
|
PROVISC(SOD.HYALUR 10MG/.85ML
|
Facility
|
OP
|
$607.72
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
25003393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.00 |
| Max. Negotiated Rate |
$583.41 |
| Rate for Payer: Aetna Commercial |
$467.94
|
| Rate for Payer: Anthem Medicaid |
$208.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$474.02
|
| Rate for Payer: Cash Price |
$303.86
|
| Rate for Payer: Cigna Commercial |
$504.41
|
| Rate for Payer: First Health Commercial |
$577.33
|
| Rate for Payer: Humana Commercial |
$516.56
|
| Rate for Payer: Humana KY Medicaid |
$208.99
|
| Rate for Payer: Kentucky WC Medicaid |
$211.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$498.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$534.79
|
| Rate for Payer: Ohio Health Group HMO |
$455.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$188.39
|
| Rate for Payer: PHCS Commercial |
$583.41
|
| Rate for Payer: United Healthcare All Payer |
$534.79
|
|
|
PROVOCHOLINE(METHACHOLI) 1MG
|
Facility
|
IP
|
$144.04
|
|
|
Service Code
|
HCPCS J7674
|
| Hospital Charge Code |
25002519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.73 |
| Max. Negotiated Rate |
$138.28 |
| Rate for Payer: Aetna Commercial |
$110.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.35
|
| Rate for Payer: Cash Price |
$72.02
|
| Rate for Payer: Cigna Commercial |
$119.55
|
| Rate for Payer: First Health Commercial |
$136.84
|
| Rate for Payer: Humana Commercial |
$122.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.76
|
| Rate for Payer: Ohio Health Group HMO |
$108.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.65
|
| Rate for Payer: PHCS Commercial |
$138.28
|
| Rate for Payer: United Healthcare All Payer |
$126.76
|
|
|
PROVOCHOLINE(METHACHOLI) 1MG
|
Facility
|
OP
|
$144.04
|
|
|
Service Code
|
HCPCS J7674
|
| Hospital Charge Code |
25002519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.73 |
| Max. Negotiated Rate |
$138.28 |
| Rate for Payer: Aetna Commercial |
$110.91
|
| Rate for Payer: Anthem Medicaid |
$49.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.35
|
| Rate for Payer: Cash Price |
$72.02
|
| Rate for Payer: Cigna Commercial |
$119.55
|
| Rate for Payer: First Health Commercial |
$136.84
|
| Rate for Payer: Humana Commercial |
$122.43
|
| Rate for Payer: Humana KY Medicaid |
$49.54
|
| Rate for Payer: Kentucky WC Medicaid |
$50.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.76
|
| Rate for Payer: Ohio Health Group HMO |
$108.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.65
|
| Rate for Payer: PHCS Commercial |
$138.28
|
| Rate for Payer: United Healthcare All Payer |
$126.76
|
|
|
PROWATER PTCA GW 180CM
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem Medicaid |
$395.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Humana KY Medicaid |
$395.83
|
| Rate for Payer: Kentucky WC Medicaid |
$399.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
PROWATER PTCA GW 180CM
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
PROX REAMING GUIDE
|
Facility
|
IP
|
$3,187.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$414.31 |
| Max. Negotiated Rate |
$3,059.52 |
| Rate for Payer: Aetna Commercial |
$2,453.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,485.86
|
| Rate for Payer: Cash Price |
$1,593.50
|
| Rate for Payer: Cigna Commercial |
$2,645.21
|
| Rate for Payer: First Health Commercial |
$3,027.65
|
| Rate for Payer: Humana Commercial |
$2,708.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,613.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,352.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,804.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,390.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$987.97
|
| Rate for Payer: PHCS Commercial |
$3,059.52
|
| Rate for Payer: United Healthcare All Payer |
$2,804.56
|
|
|
PROX REAMING GUIDE
|
Facility
|
OP
|
$3,187.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$414.31 |
| Max. Negotiated Rate |
$3,059.52 |
| Rate for Payer: Aetna Commercial |
$2,453.99
|
| Rate for Payer: Anthem Medicaid |
$1,096.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,485.86
|
| Rate for Payer: Cash Price |
$1,593.50
|
| Rate for Payer: Cigna Commercial |
$2,645.21
|
| Rate for Payer: First Health Commercial |
$3,027.65
|
| Rate for Payer: Humana Commercial |
$2,708.95
|
| Rate for Payer: Humana KY Medicaid |
$1,096.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,107.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,613.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,352.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,118.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,804.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,390.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$987.97
|
| Rate for Payer: PHCS Commercial |
$3,059.52
|
| Rate for Payer: United Healthcare All Payer |
$2,804.56
|
|
