|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
IP
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
636T0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.74 |
| Max. Negotiated Rate |
$827.96 |
| Rate for Payer: Aetna Commercial |
$664.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.72
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cigna Commercial |
$715.84
|
| Rate for Payer: First Health Commercial |
$819.34
|
| Rate for Payer: Humana Commercial |
$733.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.96
|
| Rate for Payer: Ohio Health Group HMO |
$646.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.10
|
| Rate for Payer: PHCS Commercial |
$827.96
|
| Rate for Payer: United Healthcare All Payer |
$758.96
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
OP
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
636T0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.74 |
| Max. Negotiated Rate |
$827.96 |
| Rate for Payer: Aetna Commercial |
$664.09
|
| Rate for Payer: Anthem Medicaid |
$296.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.72
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cigna Commercial |
$715.84
|
| Rate for Payer: First Health Commercial |
$819.34
|
| Rate for Payer: Humana Commercial |
$733.09
|
| Rate for Payer: Humana KY Medicaid |
$296.60
|
| Rate for Payer: Kentucky WC Medicaid |
$299.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.96
|
| Rate for Payer: Ohio Health Group HMO |
$646.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.10
|
| Rate for Payer: PHCS Commercial |
$827.96
|
| Rate for Payer: United Healthcare All Payer |
$758.96
|
|
|
PREVNAR 20 SYR (PNEUMOCOCCAL)
|
Facility
|
IP
|
$862.46
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
63600164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.74 |
| Max. Negotiated Rate |
$827.96 |
| Rate for Payer: Aetna Commercial |
$664.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.72
|
| Rate for Payer: Cash Price |
$431.23
|
| Rate for Payer: Cigna Commercial |
$715.84
|
| Rate for Payer: First Health Commercial |
$819.34
|
| Rate for Payer: Humana Commercial |
$733.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.96
|
| Rate for Payer: Ohio Health Group HMO |
$646.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.10
|
| Rate for Payer: PHCS Commercial |
$827.96
|
| Rate for Payer: United Healthcare All Payer |
$758.96
|
|
|
PREV VISIT NEW AGE 12-17
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
PREV VISIT NEW AGE 12-17
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$192.50 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$101.22
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$101.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.24
|
| Rate for Payer: Molina Healthcare Passport |
$101.22
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.23
|
|
|
PREV VISIT NEW AGE 12-17
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$94.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$94.57
|
| Rate for Payer: Kentucky WC Medicaid |
$95.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$96.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
PREV VISIT NEW AGE 12-17(P
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
510P0099
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$192.50 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$101.22
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$101.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.24
|
| Rate for Payer: Molina Healthcare Passport |
$101.22
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.23
|
|
|
PREZISTA (DARUNAVIR) 800MG
|
Facility
|
OP
|
$143.94
|
|
|
Service Code
|
NDC 59676056630
|
| Hospital Charge Code |
25003813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.18 |
| Max. Negotiated Rate |
$138.18 |
| Rate for Payer: Aetna Commercial |
$110.83
|
| Rate for Payer: Anthem Medicaid |
$49.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.27
|
| Rate for Payer: Cash Price |
$71.97
|
| Rate for Payer: Cigna Commercial |
$119.47
|
| Rate for Payer: First Health Commercial |
$136.74
|
| Rate for Payer: Humana Commercial |
$122.35
|
| Rate for Payer: Humana KY Medicaid |
$49.50
|
| Rate for Payer: Kentucky WC Medicaid |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.67
|
| Rate for Payer: Ohio Health Group HMO |
$107.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.32
|
| Rate for Payer: PHCS Commercial |
$138.18
|
| Rate for Payer: United Healthcare All Payer |
$126.67
|
|
|
PREZISTA (DARUNAVIR) 800MG
|
Facility
|
IP
|
$143.94
|
|
|
Service Code
|
NDC 59676056630
|
| Hospital Charge Code |
25003813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.18 |
| Max. Negotiated Rate |
$138.18 |
| Rate for Payer: Aetna Commercial |
$110.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.27
|
| Rate for Payer: Cash Price |
$71.97
|
| Rate for Payer: Cigna Commercial |
$119.47
|
| Rate for Payer: First Health Commercial |
$136.74
|
| Rate for Payer: Humana Commercial |
$122.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.67
|
| Rate for Payer: Ohio Health Group HMO |
$107.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.32
|
| Rate for Payer: PHCS Commercial |
$138.18
|
| Rate for Payer: United Healthcare All Payer |
$126.67
|
|
|
PRGRMG DEV EVAL SCRMS IP
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS 93285
|
| Hospital Charge Code |
48000082
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.46 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem Medicaid |
$67.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.52
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Humana KY Medicaid |
$67.40
|
| Rate for Payer: Humana Medicare Advantage |
$34.46
|
| Rate for Payer: Kentucky WC Medicaid |
$68.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.24
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
PRGRMG DEV EVAL SCRMS IP
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
HCPCS 93285
|
| Hospital Charge Code |
48000082
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.24
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
PRGRMG EVAL IMPLANTABLE DFB
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
HCPCS 93284
|
| Hospital Charge Code |
48000081
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$57.30 |
| Max. Negotiated Rate |
$183.36 |
| Rate for Payer: Aetna Commercial |
$147.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.98
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$158.53
|
| Rate for Payer: First Health Commercial |
$181.45
|
| Rate for Payer: Humana Commercial |
$162.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.08
|
| Rate for Payer: Ohio Health Group HMO |
$143.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.79
|
| Rate for Payer: PHCS Commercial |
$183.36
|
| Rate for Payer: United Healthcare All Payer |
$168.08
|
|
|
PRGRMG EVAL IMPLANTABLE DFB
|
Professional
|
Both
|
$191.00
|
|
|
Service Code
|
HCPCS 93284
|
| Hospital Charge Code |
48000081
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$66.85 |
| Max. Negotiated Rate |
$167.48 |
| Rate for Payer: Aetna Commercial |
$165.49
|
| Rate for Payer: Ambetter Exchange |
$95.73
|
| Rate for Payer: Anthem Medicaid |
$83.67
|
| Rate for Payer: Buckeye Individual/Medicaid |
$95.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$95.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.88
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$167.48
|
| Rate for Payer: Healthspan PPO |
$155.55
|
| Rate for Payer: Humana Medicaid |
$83.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.13
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$95.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$95.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.34
|
| Rate for Payer: Molina Healthcare Passport |
$83.67
|
| Rate for Payer: Multiplan PHCS |
$114.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$124.45
|
| Rate for Payer: UHCCP Medicaid |
$66.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$95.73
|
|
|
PRGRMG EVAL IMPLANTABLE DFB
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
HCPCS 93284
|
| Hospital Charge Code |
48000081
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.46 |
| Max. Negotiated Rate |
$183.36 |
| Rate for Payer: Aetna Commercial |
$147.07
|
| Rate for Payer: Anthem Medicaid |
$65.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.52
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$158.53
|
| Rate for Payer: First Health Commercial |
$181.45
|
| Rate for Payer: Humana Commercial |
$162.35
|
| Rate for Payer: Humana KY Medicaid |
$65.68
|
| Rate for Payer: Humana Medicare Advantage |
$34.46
|
| Rate for Payer: Kentucky WC Medicaid |
$66.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.08
|
| Rate for Payer: Ohio Health Group HMO |
$143.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.79
|
| Rate for Payer: PHCS Commercial |
$183.36
|
| Rate for Payer: United Healthcare All Payer |
$168.08
|
|
|
PRILOSEC (OMEPRAZOLE 10MG/1CAP
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 68462039501
|
| Hospital Charge Code |
25001229
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PRILOSEC (OMEPRAZOLE 10MG/1CAP
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 68462039501
|
| Hospital Charge Code |
25001229
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PRILOSEC (OMEPRAZOLE 20MG/1CAP
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 68084012801
|
| Hospital Charge Code |
25001230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
PRILOSEC (OMEPRAZOLE 20MG/1CAP
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 68084012801
|
| Hospital Charge Code |
25001230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
PRIMACOR 5MG (10MG/10ML VIAL)
|
Facility
|
IP
|
$115.12
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.54 |
| Max. Negotiated Rate |
$110.52 |
| Rate for Payer: Aetna Commercial |
$88.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.79
|
| Rate for Payer: Cash Price |
$57.56
|
| Rate for Payer: Cigna Commercial |
$95.55
|
| Rate for Payer: First Health Commercial |
$109.36
|
| Rate for Payer: Humana Commercial |
$97.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.31
|
| Rate for Payer: Ohio Health Group HMO |
$86.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.43
|
| Rate for Payer: PHCS Commercial |
$110.52
|
| Rate for Payer: United Healthcare All Payer |
$101.31
|
|
|
PRIMACOR 5MG (10MG/10ML VIAL)
|
Facility
|
OP
|
$115.12
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.54 |
| Max. Negotiated Rate |
$110.52 |
| Rate for Payer: Aetna Commercial |
$88.64
|
| Rate for Payer: Anthem Medicaid |
$39.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.79
|
| Rate for Payer: Cash Price |
$57.56
|
| Rate for Payer: Cigna Commercial |
$95.55
|
| Rate for Payer: First Health Commercial |
$109.36
|
| Rate for Payer: Humana Commercial |
$97.85
|
| Rate for Payer: Humana KY Medicaid |
$39.59
|
| Rate for Payer: Kentucky WC Medicaid |
$39.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.31
|
| Rate for Payer: Ohio Health Group HMO |
$86.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.43
|
| Rate for Payer: PHCS Commercial |
$110.52
|
| Rate for Payer: United Healthcare All Payer |
$101.31
|
|
|
PRIMACORMILRINONE5MG200MG/DEX
|
Facility
|
OP
|
$116.50
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.95 |
| Max. Negotiated Rate |
$111.84 |
| Rate for Payer: Aetna Commercial |
$89.70
|
| Rate for Payer: Anthem Medicaid |
$40.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.87
|
| Rate for Payer: Cash Price |
$58.25
|
| Rate for Payer: Cigna Commercial |
$96.69
|
| Rate for Payer: First Health Commercial |
$110.67
|
| Rate for Payer: Humana Commercial |
$99.03
|
| Rate for Payer: Humana KY Medicaid |
$40.06
|
| Rate for Payer: Kentucky WC Medicaid |
$40.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.52
|
| Rate for Payer: Ohio Health Group HMO |
$87.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.39
|
| Rate for Payer: PHCS Commercial |
$111.84
|
| Rate for Payer: United Healthcare All Payer |
$102.52
|
|
|
PRIMACORMILRINONE5MG200MG/DEX
|
Facility
|
IP
|
$116.50
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.95 |
| Max. Negotiated Rate |
$111.84 |
| Rate for Payer: Aetna Commercial |
$89.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.87
|
| Rate for Payer: Cash Price |
$58.25
|
| Rate for Payer: Cigna Commercial |
$96.69
|
| Rate for Payer: First Health Commercial |
$110.67
|
| Rate for Payer: Humana Commercial |
$99.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.52
|
| Rate for Payer: Ohio Health Group HMO |
$87.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.39
|
| Rate for Payer: PHCS Commercial |
$111.84
|
| Rate for Payer: United Healthcare All Payer |
$102.52
|
|
|
PRIMAQUINE 26.3MG TAB
|
Facility
|
OP
|
$10.05
|
|
|
Service Code
|
NDC 24159601
|
| Hospital Charge Code |
25004571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Aetna Commercial |
$7.74
|
| Rate for Payer: Anthem Medicaid |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.84
|
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Cigna Commercial |
$8.34
|
| Rate for Payer: First Health Commercial |
$9.55
|
| Rate for Payer: Humana Commercial |
$8.54
|
| Rate for Payer: Humana KY Medicaid |
$3.46
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.65
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
PRIMAQUINE 26.3MG TAB
|
Facility
|
IP
|
$10.05
|
|
|
Service Code
|
NDC 24159601
|
| Hospital Charge Code |
25004571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Aetna Commercial |
$7.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.84
|
| Rate for Payer: Cash Price |
$5.03
|
| Rate for Payer: Cigna Commercial |
$8.34
|
| Rate for Payer: First Health Commercial |
$9.55
|
| Rate for Payer: Humana Commercial |
$8.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.65
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
PRIM ART M-THRMBC 1ST VSL
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 37184
|
| Hospital Charge Code |
76101525
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.20 |
| Max. Negotiated Rate |
$2,801.50 |
| Rate for Payer: Aetna Commercial |
$725.36
|
| Rate for Payer: Ambetter Exchange |
$402.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$332.20
|
| Rate for Payer: Anthem Medicaid |
$2,105.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$402.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$402.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$482.51
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$668.09
|
| Rate for Payer: Healthspan PPO |
$2,801.50
|
| Rate for Payer: Humana Medicaid |
$2,105.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$604.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$402.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$402.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$2,147.92
|
| Rate for Payer: Molina Healthcare Passport |
$2,105.80
|
| Rate for Payer: Multiplan PHCS |
$1,860.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$522.72
|
| Rate for Payer: UHCCP Medicaid |
$348.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,126.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$402.09
|
|
