|
PROX TIBA LK PL3.5*4HL LFT
|
Facility
|
IP
|
$6,654.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$865.07 |
| Max. Negotiated Rate |
$6,388.22 |
| Rate for Payer: Aetna Commercial |
$5,123.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,190.43
|
| Rate for Payer: Cash Price |
$3,327.20
|
| Rate for Payer: Cigna Commercial |
$5,523.15
|
| Rate for Payer: First Health Commercial |
$6,321.68
|
| Rate for Payer: Humana Commercial |
$5,656.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,456.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,910.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,996.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,855.87
|
| Rate for Payer: Ohio Health Group HMO |
$4,990.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,330.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$865.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,062.86
|
| Rate for Payer: PHCS Commercial |
$6,388.22
|
| Rate for Payer: United Healthcare All Payer |
$5,855.87
|
|
|
PROX TIBA LK PL3.5*4HL LFT
|
Facility
|
OP
|
$6,654.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$865.07 |
| Max. Negotiated Rate |
$6,388.22 |
| Rate for Payer: Aetna Commercial |
$5,123.89
|
| Rate for Payer: Anthem Medicaid |
$2,288.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,190.43
|
| Rate for Payer: Cash Price |
$3,327.20
|
| Rate for Payer: Cigna Commercial |
$5,523.15
|
| Rate for Payer: First Health Commercial |
$6,321.68
|
| Rate for Payer: Humana Commercial |
$5,656.24
|
| Rate for Payer: Humana KY Medicaid |
$2,288.45
|
| Rate for Payer: Kentucky WC Medicaid |
$2,311.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,456.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,910.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,996.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,334.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,855.87
|
| Rate for Payer: Ohio Health Group HMO |
$4,990.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,330.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$865.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,062.86
|
| Rate for Payer: PHCS Commercial |
$6,388.22
|
| Rate for Payer: United Healthcare All Payer |
$5,855.87
|
|
|
PROZAC (FLUOXETINE) 20MG/1CAP
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 68001040000
|
| Hospital Charge Code |
25001270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PROZAC (FLUOXETINE) 20MG/1CAP
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 68001040000
|
| Hospital Charge Code |
25001270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PROZAC (FLUOXETINE) 2 20MG/5ML
|
Facility
|
OP
|
$10.88
|
|
|
Service Code
|
NDC 54838052340
|
| Hospital Charge Code |
25001271
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Anthem Medicaid |
$3.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.03
|
| Rate for Payer: First Health Commercial |
$10.34
|
| Rate for Payer: Humana Commercial |
$9.25
|
| Rate for Payer: Humana KY Medicaid |
$3.74
|
| Rate for Payer: Kentucky WC Medicaid |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.57
|
| Rate for Payer: Ohio Health Group HMO |
$8.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$10.44
|
| Rate for Payer: United Healthcare All Payer |
$9.57
|
|
|
PROZAC (FLUOXETINE) 2 20MG/5ML
|
Facility
|
IP
|
$10.88
|
|
|
Service Code
|
NDC 54838052340
|
| Hospital Charge Code |
25001271
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.03
|
| Rate for Payer: First Health Commercial |
$10.34
|
| Rate for Payer: Humana Commercial |
$9.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.57
|
| Rate for Payer: Ohio Health Group HMO |
$8.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$10.44
|
| Rate for Payer: United Healthcare All Payer |
$9.57
|
|
|
PROZAC (FLUOXETINE) CAP 10MG
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 50111064701
|
| Hospital Charge Code |
25001272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
|
|
PROZAC (FLUOXETINE) CAP 10MG
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 50111064701
|
| Hospital Charge Code |
25001272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
PROZAC WEEKLY 90MG CAPSULE DR
|
Facility
|
IP
|
$70.67
|
|
|
Service Code
|
NDC 55111028448
|
| Hospital Charge Code |
25001274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$67.84 |
| Rate for Payer: Aetna Commercial |
$54.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.12
|
| Rate for Payer: Cash Price |
$35.34
|
| Rate for Payer: Cigna Commercial |
$58.66
|
| Rate for Payer: First Health Commercial |
$67.14
|
| Rate for Payer: Humana Commercial |
$60.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.19
|
| Rate for Payer: Ohio Health Group HMO |
$53.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.91
|
| Rate for Payer: PHCS Commercial |
$67.84
|
| Rate for Payer: United Healthcare All Payer |
$62.19
|
|
|
PROZAC WEEKLY 90MG CAPSULE DR
|
Facility
|
OP
|
$70.67
|
|
|
Service Code
|
NDC 55111028448
|
| Hospital Charge Code |
25001274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$67.84 |
| Rate for Payer: Aetna Commercial |
$54.42
|
| Rate for Payer: Anthem Medicaid |
$24.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.12
|
| Rate for Payer: Cash Price |
$35.34
|
| Rate for Payer: Cigna Commercial |
$58.66
|
| Rate for Payer: First Health Commercial |
$67.14
|
| Rate for Payer: Humana Commercial |
$60.07
|
| Rate for Payer: Humana KY Medicaid |
$24.30
|
| Rate for Payer: Kentucky WC Medicaid |
$24.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.19
|
| Rate for Payer: Ohio Health Group HMO |
$53.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.91
|
| Rate for Payer: PHCS Commercial |
$67.84
|
| Rate for Payer: United Healthcare All Payer |
$62.19
|
|
|
PRQ CARD ANGIO/ATHRECT 1 AR(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
761P2455
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Anthem Medicaid |
$517.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$1,149.05
|
| Rate for Payer: Healthspan PPO |
$761.26
|
| Rate for Payer: Humana Medicaid |
$517.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$821.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$527.45
|
| Rate for Payer: Molina Healthcare Passport |
$517.11
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$522.28
|
|
|
PRQ CARD ANGIO/ATHRECT 1 AR(T
|
Facility
|
IP
|
$21,101.13
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
761T2455
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,743.15 |
| Max. Negotiated Rate |
$20,257.08 |
| Rate for Payer: Aetna Commercial |
$16,247.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,458.88
|
| Rate for Payer: Cash Price |
$10,550.57
|
| Rate for Payer: Cigna Commercial |
$17,513.94
|
| Rate for Payer: First Health Commercial |
$20,046.07
|
| Rate for Payer: Humana Commercial |
$17,935.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,302.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,572.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,330.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,568.99
|
| Rate for Payer: Ohio Health Group HMO |
$15,825.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,220.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,743.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,541.35
|
| Rate for Payer: PHCS Commercial |
$20,257.08
|
| Rate for Payer: United Healthcare All Payer |
$18,568.99
|
|
|
PRQ CARD ANGIO/ATHRECT 1 AR(T
|
Facility
|
OP
|
$21,101.13
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
761T2455
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,743.15 |
| Max. Negotiated Rate |
$20,257.08 |
| Rate for Payer: Aetna Commercial |
$16,247.87
|
| Rate for Payer: Anthem Medicaid |
$7,256.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,513.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,458.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,318.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,842.94
|
| Rate for Payer: Cash Price |
$10,550.57
|
| Rate for Payer: Cash Price |
$10,550.57
|
| Rate for Payer: Cigna Commercial |
$17,513.94
|
| Rate for Payer: First Health Commercial |
$20,046.07
|
| Rate for Payer: Humana Commercial |
$17,935.96
|
| Rate for Payer: Humana KY Medicaid |
$7,256.68
|
| Rate for Payer: Humana Medicare Advantage |
$9,513.29
|
| Rate for Payer: Kentucky WC Medicaid |
$7,330.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,302.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,572.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,415.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,402.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,568.99
|
| Rate for Payer: Ohio Health Group HMO |
$15,825.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,220.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,743.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,541.35
|
| Rate for Payer: PHCS Commercial |
$20,257.08
|
| Rate for Payer: United Healthcare All Payer |
$18,568.99
|
|
|
PRQ CARD ANGIO/ATHRECT 1 ART
|
Facility
|
OP
|
$16,010.00
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
48100046
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,081.30 |
| Max. Negotiated Rate |
$15,369.60 |
| Rate for Payer: Aetna Commercial |
$12,327.70
|
| Rate for Payer: Anthem Medicaid |
$5,505.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,513.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,487.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,318.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,842.94
|
| Rate for Payer: Cash Price |
$8,005.00
|
| Rate for Payer: Cash Price |
$8,005.00
|
| Rate for Payer: Cigna Commercial |
$13,288.30
|
| Rate for Payer: First Health Commercial |
$15,209.50
|
| Rate for Payer: Humana Commercial |
$13,608.50
|
| Rate for Payer: Humana KY Medicaid |
$5,505.84
|
| Rate for Payer: Humana Medicare Advantage |
$9,513.29
|
| Rate for Payer: Kentucky WC Medicaid |
$5,561.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,128.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,815.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,415.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,616.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,088.80
|
| Rate for Payer: Ohio Health Group HMO |
$12,007.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,202.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,081.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,963.10
|
| Rate for Payer: PHCS Commercial |
$15,369.60
|
| Rate for Payer: United Healthcare All Payer |
$14,088.80
|
|
|
PRQ CARD ANGIO/ATHRECT 1 ART
|
Facility
|
OP
|
$22,301.13
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
76102455
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,899.15 |
| Max. Negotiated Rate |
$21,409.08 |
| Rate for Payer: Aetna Commercial |
$17,171.87
|
| Rate for Payer: Anthem Medicaid |
$7,669.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,513.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,394.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,318.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,842.94
|
| Rate for Payer: Cash Price |
$11,150.57
|
| Rate for Payer: Cash Price |
$11,150.57
|
| Rate for Payer: Cigna Commercial |
$18,509.94
|
| Rate for Payer: First Health Commercial |
$21,186.07
|
| Rate for Payer: Humana Commercial |
$18,955.96
|
| Rate for Payer: Humana KY Medicaid |
$7,669.36
|
| Rate for Payer: Humana Medicare Advantage |
$9,513.29
|
| Rate for Payer: Kentucky WC Medicaid |
$7,747.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,286.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,458.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,415.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,823.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,624.99
|
| Rate for Payer: Ohio Health Group HMO |
$16,725.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,460.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,899.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,913.35
|
| Rate for Payer: PHCS Commercial |
$21,409.08
|
| Rate for Payer: United Healthcare All Payer |
$19,624.99
|
|
|
PRQ CARD ANGIO/ATHRECT 1 ART
|
Professional
|
Both
|
$22,301.13
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
76102455
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$517.11 |
| Max. Negotiated Rate |
$22,301.13 |
| Rate for Payer: Anthem Medicaid |
$517.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$22,301.13
|
| Rate for Payer: Cash Price |
$11,150.57
|
| Rate for Payer: Cash Price |
$11,150.57
|
| Rate for Payer: Cigna Commercial |
$1,149.05
|
| Rate for Payer: Healthspan PPO |
$761.26
|
| Rate for Payer: Humana Medicaid |
$517.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$821.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$527.45
|
| Rate for Payer: Molina Healthcare Passport |
$517.11
|
| Rate for Payer: Multiplan PHCS |
$13,380.68
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15,610.79
|
| Rate for Payer: UHCCP Medicaid |
$7,805.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$522.28
|
|
|
PRQ CARD ANGIO/ATHRECT 1 ART
|
Facility
|
IP
|
$22,301.13
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
76102455
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,899.15 |
| Max. Negotiated Rate |
$21,409.08 |
| Rate for Payer: Aetna Commercial |
$17,171.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,394.88
|
| Rate for Payer: Cash Price |
$11,150.57
|
| Rate for Payer: Cigna Commercial |
$18,509.94
|
| Rate for Payer: First Health Commercial |
$21,186.07
|
| Rate for Payer: Humana Commercial |
$18,955.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,286.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,458.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,690.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,624.99
|
| Rate for Payer: Ohio Health Group HMO |
$16,725.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,460.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,899.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,913.35
|
| Rate for Payer: PHCS Commercial |
$21,409.08
|
| Rate for Payer: United Healthcare All Payer |
$19,624.99
|
|
|
PRQ CARD ANGIO/ATHRECT 1 ART
|
Facility
|
IP
|
$16,010.00
|
|
|
Service Code
|
HCPCS 92924
|
| Hospital Charge Code |
48100046
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,081.30 |
| Max. Negotiated Rate |
$15,369.60 |
| Rate for Payer: Aetna Commercial |
$12,327.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,487.80
|
| Rate for Payer: Cash Price |
$8,005.00
|
| Rate for Payer: Cigna Commercial |
$13,288.30
|
| Rate for Payer: First Health Commercial |
$15,209.50
|
| Rate for Payer: Humana Commercial |
$13,608.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,128.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,815.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,803.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,088.80
|
| Rate for Payer: Ohio Health Group HMO |
$12,007.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,202.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,081.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,963.10
|
| Rate for Payer: PHCS Commercial |
$15,369.60
|
| Rate for Payer: United Healthcare All Payer |
$14,088.80
|
|
|
PRQ CARD ANGIO ATHRECT ADDL
|
Facility
|
IP
|
$14,722.00
|
|
|
Service Code
|
HCPCS 92925
|
| Hospital Charge Code |
76102456
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,913.86 |
| Max. Negotiated Rate |
$14,133.12 |
| Rate for Payer: Aetna Commercial |
$11,335.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,483.16
|
| Rate for Payer: Cash Price |
$7,361.00
|
| Rate for Payer: Cigna Commercial |
$12,219.26
|
| Rate for Payer: First Health Commercial |
$13,985.90
|
| Rate for Payer: Humana Commercial |
$12,513.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,072.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,864.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,416.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,955.36
|
| Rate for Payer: Ohio Health Group HMO |
$11,041.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,944.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,913.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,563.82
|
| Rate for Payer: PHCS Commercial |
$14,133.12
|
| Rate for Payer: United Healthcare All Payer |
$12,955.36
|
|
|
PRQ CARD ANGIO ATHRECT ADDL
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 92925
|
| Hospital Charge Code |
76102456
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
|
|
PRQ CARD ANGIO ATHRECT ADDL
|
Facility
|
OP
|
$14,722.00
|
|
|
Service Code
|
HCPCS 92925
|
| Hospital Charge Code |
76102456
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,913.86 |
| Max. Negotiated Rate |
$14,133.12 |
| Rate for Payer: Aetna Commercial |
$11,335.94
|
| Rate for Payer: Anthem Medicaid |
$5,062.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,483.16
|
| Rate for Payer: Cash Price |
$7,361.00
|
| Rate for Payer: Cigna Commercial |
$12,219.26
|
| Rate for Payer: First Health Commercial |
$13,985.90
|
| Rate for Payer: Humana Commercial |
$12,513.70
|
| Rate for Payer: Humana KY Medicaid |
$5,062.90
|
| Rate for Payer: Kentucky WC Medicaid |
$5,114.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,072.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,864.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,416.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,164.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,955.36
|
| Rate for Payer: Ohio Health Group HMO |
$11,041.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,944.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,913.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,563.82
|
| Rate for Payer: PHCS Commercial |
$14,133.12
|
| Rate for Payer: United Healthcare All Payer |
$12,955.36
|
|
|
PRQ CARDIAC ANGIO ADDL ART
|
Facility
|
IP
|
$8,982.00
|
|
|
Service Code
|
HCPCS 92921
|
| Hospital Charge Code |
48100045
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,167.66 |
| Max. Negotiated Rate |
$8,622.72 |
| Rate for Payer: Aetna Commercial |
$6,916.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,005.96
|
| Rate for Payer: Cash Price |
$4,491.00
|
| Rate for Payer: Cigna Commercial |
$7,455.06
|
| Rate for Payer: First Health Commercial |
$8,532.90
|
| Rate for Payer: Humana Commercial |
$7,634.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,365.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,628.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,694.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,904.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,736.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,796.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,167.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,784.42
|
| Rate for Payer: PHCS Commercial |
$8,622.72
|
| Rate for Payer: United Healthcare All Payer |
$7,904.16
|
|
|
PRQ CARDIAC ANGIO ADDL ART
|
Facility
|
OP
|
$11,507.00
|
|
|
Service Code
|
HCPCS 92921
|
| Hospital Charge Code |
76102454
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,495.91 |
| Max. Negotiated Rate |
$11,046.72 |
| Rate for Payer: Aetna Commercial |
$8,860.39
|
| Rate for Payer: Anthem Medicaid |
$3,957.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,975.46
|
| Rate for Payer: Cash Price |
$5,753.50
|
| Rate for Payer: Cigna Commercial |
$9,550.81
|
| Rate for Payer: First Health Commercial |
$10,931.65
|
| Rate for Payer: Humana Commercial |
$9,780.95
|
| Rate for Payer: Humana KY Medicaid |
$3,957.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3,997.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,435.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,492.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,452.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,036.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,126.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,630.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,301.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,495.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,567.17
|
| Rate for Payer: PHCS Commercial |
$11,046.72
|
| Rate for Payer: United Healthcare All Payer |
$10,126.16
|
|
|
PRQ CARDIAC ANGIO ADDL ART
|
Facility
|
IP
|
$11,507.00
|
|
|
Service Code
|
HCPCS 92921
|
| Hospital Charge Code |
76102454
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,495.91 |
| Max. Negotiated Rate |
$11,046.72 |
| Rate for Payer: Aetna Commercial |
$8,860.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,975.46
|
| Rate for Payer: Cash Price |
$5,753.50
|
| Rate for Payer: Cigna Commercial |
$9,550.81
|
| Rate for Payer: First Health Commercial |
$10,931.65
|
| Rate for Payer: Humana Commercial |
$9,780.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,435.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,492.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,452.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,126.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,630.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,301.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,495.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,567.17
|
| Rate for Payer: PHCS Commercial |
$11,046.72
|
| Rate for Payer: United Healthcare All Payer |
$10,126.16
|
|
|
PRQ CARDIAC ANGIO ADDL ART
|
Professional
|
Both
|
$11,507.00
|
|
|
Service Code
|
HCPCS 92921
|
| Hospital Charge Code |
76102454
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$11,507.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$11,507.00
|
| Rate for Payer: Cash Price |
$5,753.50
|
| Rate for Payer: Cash Price |
$5,753.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$6,904.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8,054.90
|
| Rate for Payer: UHCCP Medicaid |
$4,027.45
|
|
