|
PRISTIQ 25MG EQUIV TABLET ER
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 8121030
|
| Hospital Charge Code |
25003383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRISTIQ 25MG EQUIV TABLET ER
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 8121030
|
| Hospital Charge Code |
25003383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem Medicaid |
$10.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Humana KY Medicaid |
$10.87
|
| Rate for Payer: Kentucky WC Medicaid |
$10.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRISTIQ 50MG TABLET
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 8121101
|
| Hospital Charge Code |
25001237
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem Medicaid |
$10.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Humana KY Medicaid |
$10.87
|
| Rate for Payer: Kentucky WC Medicaid |
$10.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRISTIQ 50MG TABLET
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 8121101
|
| Hospital Charge Code |
25001237
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$24.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.65
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna Commercial |
$26.23
|
| Rate for Payer: First Health Commercial |
$30.02
|
| Rate for Payer: Humana Commercial |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.81
|
| Rate for Payer: Ohio Health Group HMO |
$23.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.80
|
| Rate for Payer: PHCS Commercial |
$30.34
|
| Rate for Payer: United Healthcare All Payer |
$27.81
|
|
|
PRIVIGEN 500mg (10gm) SDV
|
Facility
|
OP
|
$10,456.37
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$10,038.12 |
| Rate for Payer: Aetna Commercial |
$8,051.40
|
| Rate for Payer: Anthem Medicaid |
$3,595.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$50.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,155.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$70.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.08
|
| Rate for Payer: Cash Price |
$5,228.19
|
| Rate for Payer: Cash Price |
$5,228.19
|
| Rate for Payer: Cigna Commercial |
$8,678.79
|
| Rate for Payer: First Health Commercial |
$9,933.55
|
| Rate for Payer: Humana Commercial |
$8,887.91
|
| Rate for Payer: Humana KY Medicaid |
$3,595.95
|
| Rate for Payer: Humana Medicare Advantage |
$50.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,632.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,574.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,716.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,668.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,201.61
|
| Rate for Payer: Ohio Health Group HMO |
$7,842.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,365.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,097.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,214.90
|
| Rate for Payer: PHCS Commercial |
$10,038.12
|
| Rate for Payer: United Healthcare All Payer |
$9,201.61
|
|
|
PRIVIGEN 500mg (10gm) SDV
|
Facility
|
IP
|
$10,456.37
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,136.91 |
| Max. Negotiated Rate |
$10,038.12 |
| Rate for Payer: Aetna Commercial |
$8,051.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,155.97
|
| Rate for Payer: Cash Price |
$5,228.19
|
| Rate for Payer: Cigna Commercial |
$8,678.79
|
| Rate for Payer: First Health Commercial |
$9,933.55
|
| Rate for Payer: Humana Commercial |
$8,887.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,574.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,716.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,136.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,201.61
|
| Rate for Payer: Ohio Health Group HMO |
$7,842.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,365.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,097.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,214.90
|
| Rate for Payer: PHCS Commercial |
$10,038.12
|
| Rate for Payer: United Healthcare All Payer |
$9,201.61
|
|
|
PRIVIGEN 500mg (20gm) SDV
|
Facility
|
IP
|
$20,912.74
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,273.82 |
| Max. Negotiated Rate |
$20,076.23 |
| Rate for Payer: Aetna Commercial |
$16,102.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,311.94
|
| Rate for Payer: Cash Price |
$10,456.37
|
| Rate for Payer: Cigna Commercial |
$17,357.57
|
| Rate for Payer: First Health Commercial |
$19,867.10
|
| Rate for Payer: Humana Commercial |
$17,775.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,148.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,433.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,273.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,403.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,684.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,730.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,194.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,429.79
|
| Rate for Payer: PHCS Commercial |
$20,076.23
|
| Rate for Payer: United Healthcare All Payer |
$18,403.21
|
|
|
PRIVIGEN 500mg (20gm) SDV
|
Facility
|
OP
|
$20,912.74
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$20,076.23 |
| Rate for Payer: Aetna Commercial |
$16,102.81
|
| Rate for Payer: Anthem Medicaid |
$7,191.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$50.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,311.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$70.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.08
|
| Rate for Payer: Cash Price |
$10,456.37
|
| Rate for Payer: Cash Price |
$10,456.37
|
| Rate for Payer: Cigna Commercial |
$17,357.57
|
| Rate for Payer: First Health Commercial |
$19,867.10
|
| Rate for Payer: Humana Commercial |
$17,775.83
|
| Rate for Payer: Humana KY Medicaid |
$7,191.89
|
| Rate for Payer: Humana Medicare Advantage |
$50.43
|
| Rate for Payer: Kentucky WC Medicaid |
$7,265.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,148.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,433.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,336.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,403.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,684.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,730.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,194.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,429.79
|
| Rate for Payer: PHCS Commercial |
$20,076.23
|
| Rate for Payer: United Healthcare All Payer |
$18,403.21
|
|
|
PRIVIGEN 500mg (40gm) SDV
|
Facility
|
OP
|
$41,825.48
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$40,152.46 |
| Rate for Payer: Aetna Commercial |
$32,205.62
|
| Rate for Payer: Anthem Medicaid |
$14,383.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$50.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,623.87
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$70.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.08
|
| Rate for Payer: Cash Price |
$20,912.74
|
| Rate for Payer: Cash Price |
$20,912.74
|
| Rate for Payer: Cigna Commercial |
$34,715.15
|
| Rate for Payer: First Health Commercial |
$39,734.21
|
| Rate for Payer: Humana Commercial |
$35,551.66
|
| Rate for Payer: Humana KY Medicaid |
$14,383.78
|
| Rate for Payer: Humana Medicare Advantage |
$50.43
|
| Rate for Payer: Kentucky WC Medicaid |
$14,530.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,296.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,867.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,672.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,806.42
|
| Rate for Payer: Ohio Health Group HMO |
$31,369.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,460.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,388.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,859.58
|
| Rate for Payer: PHCS Commercial |
$40,152.46
|
| Rate for Payer: United Healthcare All Payer |
$36,806.42
|
|
|
PRIVIGEN 500mg (40gm) SDV
|
Facility
|
IP
|
$41,825.48
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,547.64 |
| Max. Negotiated Rate |
$40,152.46 |
| Rate for Payer: Aetna Commercial |
$32,205.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,623.87
|
| Rate for Payer: Cash Price |
$20,912.74
|
| Rate for Payer: Cigna Commercial |
$34,715.15
|
| Rate for Payer: First Health Commercial |
$39,734.21
|
| Rate for Payer: Humana Commercial |
$35,551.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,296.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,867.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,547.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,806.42
|
| Rate for Payer: Ohio Health Group HMO |
$31,369.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,460.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,388.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,859.58
|
| Rate for Payer: PHCS Commercial |
$40,152.46
|
| Rate for Payer: United Healthcare All Payer |
$36,806.42
|
|
|
PRIVIGEN 500mg (5gm) SDV
|
Facility
|
IP
|
$5,228.19
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,568.46 |
| Max. Negotiated Rate |
$5,019.06 |
| Rate for Payer: Aetna Commercial |
$4,025.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,077.99
|
| Rate for Payer: Cash Price |
$2,614.09
|
| Rate for Payer: Cigna Commercial |
$4,339.40
|
| Rate for Payer: First Health Commercial |
$4,966.78
|
| Rate for Payer: Humana Commercial |
$4,443.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,287.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,858.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,568.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,600.81
|
| Rate for Payer: Ohio Health Group HMO |
$3,921.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,182.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,548.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,607.45
|
| Rate for Payer: PHCS Commercial |
$5,019.06
|
| Rate for Payer: United Healthcare All Payer |
$4,600.81
|
|
|
PRIVIGEN 500mg (5gm) SDV
|
Facility
|
OP
|
$5,228.19
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
25002072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$5,019.06 |
| Rate for Payer: Aetna Commercial |
$4,025.71
|
| Rate for Payer: Anthem Medicaid |
$1,797.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$50.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,077.99
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$70.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.08
|
| Rate for Payer: Cash Price |
$2,614.09
|
| Rate for Payer: Cash Price |
$2,614.09
|
| Rate for Payer: Cigna Commercial |
$4,339.40
|
| Rate for Payer: First Health Commercial |
$4,966.78
|
| Rate for Payer: Humana Commercial |
$4,443.96
|
| Rate for Payer: Humana KY Medicaid |
$1,797.97
|
| Rate for Payer: Humana Medicare Advantage |
$50.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1,816.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,287.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,858.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,834.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,600.81
|
| Rate for Payer: Ohio Health Group HMO |
$3,921.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,182.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,548.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,607.45
|
| Rate for Payer: PHCS Commercial |
$5,019.06
|
| Rate for Payer: United Healthcare All Payer |
$4,600.81
|
|
|
PROAMATINE(MIDODRINE)2.5MG TAB
|
Facility
|
IP
|
$5.18
|
|
|
Service Code
|
NDC 60687038701
|
| Hospital Charge Code |
25001240
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$3.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.04
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cigna Commercial |
$4.30
|
| Rate for Payer: First Health Commercial |
$4.92
|
| Rate for Payer: Humana Commercial |
$4.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.56
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.57
|
| Rate for Payer: PHCS Commercial |
$4.97
|
| Rate for Payer: United Healthcare All Payer |
$4.56
|
|
|
PROAMATINE(MIDODRINE)2.5MG TAB
|
Facility
|
OP
|
$5.18
|
|
|
Service Code
|
NDC 60687038701
|
| Hospital Charge Code |
25001240
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$3.99
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.04
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cigna Commercial |
$4.30
|
| Rate for Payer: First Health Commercial |
$4.92
|
| Rate for Payer: Humana Commercial |
$4.40
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.56
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.57
|
| Rate for Payer: PHCS Commercial |
$4.97
|
| Rate for Payer: United Healthcare All Payer |
$4.56
|
|
|
PROAMATINE (MIDODRINE 5MG TAB)
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 60687039801
|
| Hospital Charge Code |
25001239
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
PROAMATINE (MIDODRINE 5MG TAB)
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 60687039801
|
| Hospital Charge Code |
25001239
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
PROBE KIT 10MM SINGLE
|
Facility
|
IP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
PROBE KIT 10MM SINGLE
|
Facility
|
OP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem Medicaid |
$5,330.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Humana KY Medicaid |
$5,330.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,384.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,437.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
PROBE KIT 10MM X2 DUAL
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
PROBE KIT 10MM X2 DUAL
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
PROBE KIT 15MM SINGLE
|
Facility
|
IP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
PROBE KIT 15MM SINGLE
|
Facility
|
OP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem Medicaid |
$5,330.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Humana KY Medicaid |
$5,330.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,384.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,437.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
PROBE KIT 15MM X2 DUAL
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
PROBE KIT 15MM X2 DUAL
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
PROBE KIT 20MM SINGLE
|
Facility
|
OP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem Medicaid |
$5,330.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Humana KY Medicaid |
$5,330.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,384.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,437.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
