|
PRIM FULLCOAT ECH SZ 16 HO
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRIM FULLCOAT ECH SZ 16 ST
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRIM FULLCOAT ECH SZ 16 ST
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRIM FULLCOAT ECH SZ 17 HO
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRIM FULLCOAT ECH SZ 17 HO
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRIM FULLCOAT ECH SZ 17 ST
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRIM FULLCOAT ECH SZ 17 ST
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRINIVIL 2.5MG TABLET
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 60687065621
|
| Hospital Charge Code |
25001235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
PRINIVIL 2.5MG TABLET
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 60687065621
|
| Hospital Charge Code |
25001235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
PRINIVIL (LISINOPRIL) 10MG TAB
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 904679861
|
| Hospital Charge Code |
25001232
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| 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 |
$3.31
|
| 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 |
$1.27
|
| 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 |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
PRINIVIL (LISINOPRIL) 10MG TAB
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 904679861
|
| Hospital Charge Code |
25001232
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| 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: 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 |
$1.27
|
| 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 |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
PRINIVIL (LISINOPRIL) 20MG TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904679961
|
| Hospital Charge Code |
25001234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| 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 |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PRINIVIL (LISINOPRIL) 20MG TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 904679961
|
| Hospital Charge Code |
25001234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| 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 |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PRINIVIL (LISINOPRIL) 5MG TAB
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 904679761
|
| Hospital Charge Code |
25001233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| 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 |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
PRINIVIL (LISINOPRIL) 5MG TAB
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 904679761
|
| Hospital Charge Code |
25001233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| 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 |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
PRIORITY ONE ASPIRATN CATH 6F
|
Facility
|
IP
|
$3,406.25
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,021.88 |
| Max. Negotiated Rate |
$3,270.00 |
| Rate for Payer: Aetna Commercial |
$2,622.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,656.88
|
| Rate for Payer: Cash Price |
$1,703.12
|
| Rate for Payer: Cigna Commercial |
$2,827.19
|
| Rate for Payer: First Health Commercial |
$3,235.94
|
| Rate for Payer: Humana Commercial |
$2,895.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,793.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,513.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,021.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,997.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,554.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,725.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,963.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,350.31
|
| Rate for Payer: PHCS Commercial |
$3,270.00
|
| Rate for Payer: United Healthcare All Payer |
$2,997.50
|
|
|
PRIORITY ONE ASPIRATN CATH 6F
|
Facility
|
OP
|
$3,406.25
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,021.88 |
| Max. Negotiated Rate |
$3,270.00 |
| Rate for Payer: Aetna Commercial |
$2,622.81
|
| Rate for Payer: Anthem Medicaid |
$1,171.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,656.88
|
| Rate for Payer: Cash Price |
$1,703.12
|
| Rate for Payer: Cigna Commercial |
$2,827.19
|
| Rate for Payer: First Health Commercial |
$3,235.94
|
| Rate for Payer: Humana Commercial |
$2,895.31
|
| Rate for Payer: Humana KY Medicaid |
$1,171.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,183.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,793.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,513.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,021.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,194.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,997.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,554.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,725.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,963.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,350.31
|
| Rate for Payer: PHCS Commercial |
$3,270.00
|
| Rate for Payer: United Healthcare All Payer |
$2,997.50
|
|
|
PRISMASATE BGK4/2.5 CRRT SOL
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003378
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem Medicaid |
$33.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.77
|
| Rate for Payer: Humana Commercial |
$83.89
|
| Rate for Payer: Humana KY Medicaid |
$33.94
|
| Rate for Payer: Kentucky WC Medicaid |
$34.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.10
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASATE BGK4/2.5 CRRT SOL
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003378
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.77
|
| Rate for Payer: Humana Commercial |
$83.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.10
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASATE(BK2/0)5000MLCRRTSOL
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003381
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.77
|
| Rate for Payer: Humana Commercial |
$83.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.10
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASATE(BK2/0)5000MLCRRTSOL
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003381
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem Medicaid |
$33.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.77
|
| Rate for Payer: Humana Commercial |
$83.89
|
| Rate for Payer: Humana KY Medicaid |
$33.94
|
| Rate for Payer: Kentucky WC Medicaid |
$34.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.10
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASOL BGK2/0 5,000 ML SOLN
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
NDC 24571010206
|
| Hospital Charge Code |
25004234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem Medicaid |
$33.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.77
|
| Rate for Payer: Humana Commercial |
$83.89
|
| Rate for Payer: Humana KY Medicaid |
$33.94
|
| Rate for Payer: Kentucky WC Medicaid |
$34.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.10
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISMASOL BGK2/0 5,000 ML SOLN
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 24571010206
|
| Hospital Charge Code |
25004234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$94.75 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.99
|
| Rate for Payer: Cash Price |
$49.35
|
| Rate for Payer: Cigna Commercial |
$81.92
|
| Rate for Payer: First Health Commercial |
$93.77
|
| Rate for Payer: Humana Commercial |
$83.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.86
|
| Rate for Payer: Ohio Health Group HMO |
$74.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.10
|
| Rate for Payer: PHCS Commercial |
$94.75
|
| Rate for Payer: United Healthcare All Payer |
$86.86
|
|
|
PRISTIQ 100MG TABLET
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 59762122203
|
| Hospital Charge Code |
25001236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
PRISTIQ 100MG TABLET
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 59762122203
|
| Hospital Charge Code |
25001236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
