|
PROLIA 60MG/ML SYRINGE
|
Facility
|
IP
|
$10,221.09
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
25002005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,066.33 |
| Max. Negotiated Rate |
$9,812.25 |
| Rate for Payer: Aetna Commercial |
$7,870.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,972.45
|
| Rate for Payer: Cash Price |
$5,110.54
|
| Rate for Payer: Cigna Commercial |
$8,483.50
|
| Rate for Payer: First Health Commercial |
$9,710.04
|
| Rate for Payer: Humana Commercial |
$8,687.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,381.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,543.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,066.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,994.56
|
| Rate for Payer: Ohio Health Group HMO |
$7,665.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,176.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,892.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,052.55
|
| Rate for Payer: PHCS Commercial |
$9,812.25
|
| Rate for Payer: United Healthcare All Payer |
$8,994.56
|
|
|
PROLININ 2.5MG/1TAB
|
Facility
|
OP
|
$10.32
|
|
|
Service Code
|
NDC 527178901
|
| Hospital Charge Code |
25001247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.91 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem Medicaid |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.80
|
| Rate for Payer: Humana Commercial |
$8.77
|
| Rate for Payer: Humana KY Medicaid |
$3.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.08
|
| Rate for Payer: Ohio Health Group HMO |
$7.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.12
|
| Rate for Payer: PHCS Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Payer |
$9.08
|
|
|
PROLININ 2.5MG/1TAB
|
Facility
|
IP
|
$10.32
|
|
|
Service Code
|
NDC 527178901
|
| Hospital Charge Code |
25001247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.91 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.80
|
| Rate for Payer: Humana Commercial |
$8.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.08
|
| Rate for Payer: Ohio Health Group HMO |
$7.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.12
|
| Rate for Payer: PHCS Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Payer |
$9.08
|
|
|
PROLIXIN 10MG EQUIVALENT TAB
|
Facility
|
OP
|
$11.96
|
|
|
Service Code
|
NDC 527179101
|
| Hospital Charge Code |
25001250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$9.21
|
| Rate for Payer: Anthem Medicaid |
$4.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.33
|
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: Cigna Commercial |
$9.93
|
| Rate for Payer: First Health Commercial |
$11.36
|
| Rate for Payer: Humana Commercial |
$10.17
|
| Rate for Payer: Humana KY Medicaid |
$4.11
|
| Rate for Payer: Kentucky WC Medicaid |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.52
|
| Rate for Payer: Ohio Health Group HMO |
$8.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.25
|
| Rate for Payer: PHCS Commercial |
$11.48
|
| Rate for Payer: United Healthcare All Payer |
$10.52
|
|
|
PROLIXIN 10MG EQUIVALENT TAB
|
Facility
|
IP
|
$11.96
|
|
|
Service Code
|
NDC 527179101
|
| Hospital Charge Code |
25001250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$9.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.33
|
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: Cigna Commercial |
$9.93
|
| Rate for Payer: First Health Commercial |
$11.36
|
| Rate for Payer: Humana Commercial |
$10.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.52
|
| Rate for Payer: Ohio Health Group HMO |
$8.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.25
|
| Rate for Payer: PHCS Commercial |
$11.48
|
| Rate for Payer: United Healthcare All Payer |
$10.52
|
|
|
PROLIXINDECANOAT25MG/ML 5 ML V
|
Facility
|
IP
|
$549.00
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
25002324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.70 |
| Max. Negotiated Rate |
$527.04 |
| Rate for Payer: Aetna Commercial |
$422.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$428.22
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$455.67
|
| Rate for Payer: First Health Commercial |
$521.55
|
| Rate for Payer: Humana Commercial |
$466.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$450.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$483.12
|
| Rate for Payer: Ohio Health Group HMO |
$411.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$439.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.81
|
| Rate for Payer: PHCS Commercial |
$527.04
|
| Rate for Payer: United Healthcare All Payer |
$483.12
|
|
|
PROLIXINDECANOAT25MG/ML 5 ML V
|
Facility
|
OP
|
$549.00
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
25002324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.70 |
| Max. Negotiated Rate |
$527.04 |
| Rate for Payer: Aetna Commercial |
$422.73
|
| Rate for Payer: Anthem Medicaid |
$188.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$428.22
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$455.67
|
| Rate for Payer: First Health Commercial |
$521.55
|
| Rate for Payer: Humana Commercial |
$466.65
|
| Rate for Payer: Humana KY Medicaid |
$188.80
|
| Rate for Payer: Kentucky WC Medicaid |
$190.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$450.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$483.12
|
| Rate for Payer: Ohio Health Group HMO |
$411.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$439.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.81
|
| Rate for Payer: PHCS Commercial |
$527.04
|
| Rate for Payer: United Healthcare All Payer |
$483.12
|
|
|
PROLIXIN(FLUPHENA)2.5MG/5MLELX
|
Facility
|
IP
|
$10.67
|
|
|
Service Code
|
NDC 121065402
|
| Hospital Charge Code |
25001251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.32
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.14
|
| Rate for Payer: Humana Commercial |
$9.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.39
|
| Rate for Payer: Ohio Health Group HMO |
$8.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.36
|
| Rate for Payer: PHCS Commercial |
$10.24
|
| Rate for Payer: United Healthcare All Payer |
$9.39
|
|
|
PROLIXIN(FLUPHENA)2.5MG/5MLELX
|
Facility
|
OP
|
$10.67
|
|
|
Service Code
|
NDC 121065402
|
| Hospital Charge Code |
25001251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem Medicaid |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.32
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.14
|
| Rate for Payer: Humana Commercial |
$9.07
|
| Rate for Payer: Humana KY Medicaid |
$3.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.39
|
| Rate for Payer: Ohio Health Group HMO |
$8.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.36
|
| Rate for Payer: PHCS Commercial |
$10.24
|
| Rate for Payer: United Healthcare All Payer |
$9.39
|
|
|
PROLIXIN (FLUPHENAZIN 1MG/1TAB
|
Facility
|
OP
|
$4.89
|
|
|
Service Code
|
NDC 69238167801
|
| Hospital Charge Code |
25001248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.06
|
| Rate for Payer: First Health Commercial |
$4.65
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.30
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.69
|
| Rate for Payer: United Healthcare All Payer |
$4.30
|
|
|
PROLIXIN (FLUPHENAZIN 1MG/1TAB
|
Facility
|
IP
|
$4.89
|
|
|
Service Code
|
NDC 69238167801
|
| Hospital Charge Code |
25001248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.06
|
| Rate for Payer: First Health Commercial |
$4.65
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.30
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.69
|
| Rate for Payer: United Healthcare All Payer |
$4.30
|
|
|
PROLIXIN(FLUPHENAZIN 25MG/10ML
|
Facility
|
OP
|
$620.07
|
|
|
Service Code
|
NDC 63323028110
|
| Hospital Charge Code |
25003387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.02 |
| Max. Negotiated Rate |
$595.27 |
| Rate for Payer: Aetna Commercial |
$477.45
|
| Rate for Payer: Anthem Medicaid |
$213.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.65
|
| Rate for Payer: Cash Price |
$310.04
|
| Rate for Payer: Cigna Commercial |
$514.66
|
| Rate for Payer: First Health Commercial |
$589.07
|
| Rate for Payer: Humana Commercial |
$527.06
|
| Rate for Payer: Humana KY Medicaid |
$213.24
|
| Rate for Payer: Kentucky WC Medicaid |
$215.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.66
|
| Rate for Payer: Ohio Health Group HMO |
$465.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$496.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.85
|
| Rate for Payer: PHCS Commercial |
$595.27
|
| Rate for Payer: United Healthcare All Payer |
$545.66
|
|
|
PROLIXIN(FLUPHENAZIN 25MG/10ML
|
Facility
|
IP
|
$620.07
|
|
|
Service Code
|
NDC 63323028110
|
| Hospital Charge Code |
25003387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.02 |
| Max. Negotiated Rate |
$595.27 |
| Rate for Payer: Aetna Commercial |
$477.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.65
|
| Rate for Payer: Cash Price |
$310.04
|
| Rate for Payer: Cigna Commercial |
$514.66
|
| Rate for Payer: First Health Commercial |
$589.07
|
| Rate for Payer: Humana Commercial |
$527.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.66
|
| Rate for Payer: Ohio Health Group HMO |
$465.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$496.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.85
|
| Rate for Payer: PHCS Commercial |
$595.27
|
| Rate for Payer: United Healthcare All Payer |
$545.66
|
|
|
PROLIXIN (FLUPHENAZIN 5MG/1TAB
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 69238168001
|
| Hospital Charge Code |
25001249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Anthem Medicaid |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.98
|
| Rate for Payer: Humana Commercial |
$8.03
|
| Rate for Payer: Humana KY Medicaid |
$3.25
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.32
|
| Rate for Payer: Ohio Health Group HMO |
$7.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.52
|
| Rate for Payer: PHCS Commercial |
$9.07
|
| Rate for Payer: United Healthcare All Payer |
$8.32
|
|
|
PROLIXIN (FLUPHENAZIN 5MG/1TAB
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 69238168001
|
| Hospital Charge Code |
25001249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.98
|
| Rate for Payer: Humana Commercial |
$8.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.32
|
| Rate for Payer: Ohio Health Group HMO |
$7.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.52
|
| Rate for Payer: PHCS Commercial |
$9.07
|
| Rate for Payer: United Healthcare All Payer |
$8.32
|
|
|
PROLNG CLIN STAFF SVC 1ST HR
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 99415
|
| Hospital Charge Code |
51000350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem Medicaid |
$13.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Humana KY Medicaid |
$13.07
|
| Rate for Payer: Kentucky WC Medicaid |
$13.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.22
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
|
PROLNG CLIN STAFF SVC 1ST HR
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS 99415
|
| Hospital Charge Code |
51000350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.22
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
|
PROLNG CLIN STAFF SVC 1ST HR
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
HCPCS 99415
|
| Hospital Charge Code |
51000350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.46 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Ambetter Exchange |
$18.31
|
| Rate for Payer: Anthem Medicaid |
$7.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$21.97
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$13.76
|
| Rate for Payer: Humana Medicaid |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$7.61
|
| Rate for Payer: Molina Healthcare Passport |
$7.46
|
| Rate for Payer: Multiplan PHCS |
$22.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.80
|
| Rate for Payer: UHCCP Medicaid |
$13.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$7.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.31
|
|
|
PROLNG CLIN STAFF SVC EA ADD
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS 99416
|
| Hospital Charge Code |
51000351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem Medicaid |
$8.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Humana KY Medicaid |
$8.60
|
| Rate for Payer: Kentucky WC Medicaid |
$8.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
PROLNG CLIN STAFF SVC EA ADD
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS 99416
|
| Hospital Charge Code |
51000351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
PROLNG CLIN STAFF SVC EA ADD
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 99416
|
| Hospital Charge Code |
51000351
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Ambetter Exchange |
$8.59
|
| Rate for Payer: Anthem Medicaid |
$3.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.31
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: Humana Medicaid |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3.95
|
| Rate for Payer: Molina Healthcare Passport |
$3.87
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.17
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.91
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.59
|
|
|
PROLNG IP/OBS E/M EA 15 MIN
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 99418
|
| Hospital Charge Code |
51000339
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Anthem Medicaid |
$33.09
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Humana Medicaid |
$33.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.75
|
| Rate for Payer: Molina Healthcare Passport |
$33.09
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.42
|
|
|
PROLNG IP/OBS E/M EA 15 MIN(P
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 99418
|
| Hospital Charge Code |
510P0339
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Anthem Medicaid |
$33.09
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Humana Medicaid |
$33.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.75
|
| Rate for Payer: Molina Healthcare Passport |
$33.09
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.42
|
|
|
PROLNG OP E/M EACH 15 MIN
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
51000338
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$22.87
|
| Rate for Payer: Anthem Medicaid |
$26.52
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Humana Medicaid |
$26.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.05
|
| Rate for Payer: Molina Healthcare Passport |
$26.52
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$24.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.79
|
|
|
PROLNG OP E/M EACH 15 MIN(P
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
510P0338
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$38.50 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$22.87
|
| Rate for Payer: Anthem Medicaid |
$26.52
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Humana Medicaid |
$26.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.05
|
| Rate for Payer: Molina Healthcare Passport |
$26.52
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.50
|
| Rate for Payer: UHCCP Medicaid |
$24.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.79
|
|
