|
PROLONGED OUTPT/OFC VISIT
|
Professional
|
Both
|
$31.25
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
51000308
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$37.73 |
| Rate for Payer: Ambetter Exchange |
$29.02
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$22.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$29.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$29.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.82
|
| Rate for Payer: Cash Price |
$15.62
|
| Rate for Payer: Cash Price |
$15.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$29.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.02
|
| Rate for Payer: Multiplan PHCS |
$18.75
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.73
|
| Rate for Payer: UHCCP Medicaid |
$23.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$29.02
|
|
|
PROLONG HOME EVAL ADD 15
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS G0318
|
| Hospital Charge Code |
51000346
|
|
Hospital Revenue Code
|
522
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Kentucky WC Medicaid |
$26.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
PROLONG HOME EVAL ADD 15
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS G0318
|
| Hospital Charge Code |
51000346
|
|
Hospital Revenue Code
|
522
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
PROLONG HOME EVAL ADD 15
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS G0318
|
| Hospital Charge Code |
51000346
|
|
Hospital Revenue Code
|
522
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$309.74 |
| Rate for Payer: Ambetter Exchange |
$28.14
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$22.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.77
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Healthspan PPO |
$309.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$28.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.14
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$36.58
|
| Rate for Payer: UHCCP Medicaid |
$23.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.14
|
|
|
PROLONG INPT EVAL ADD 15 M
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS G0316
|
| Hospital Charge Code |
96000005
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Ambetter Exchange |
$28.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.48
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$28.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.73
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.35
|
| Rate for Payer: UHCCP Medicaid |
$24.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.73
|
|
|
PROLONG NURSING FAC EVAL 15M
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS G0317
|
| Hospital Charge Code |
51000345
|
|
Hospital Revenue Code
|
524
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
PROLONG NURSING FAC EVAL 15M
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS G0317
|
| Hospital Charge Code |
51000345
|
|
Hospital Revenue Code
|
524
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$36.96 |
| Rate for Payer: Ambetter Exchange |
$28.43
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.12
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$28.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.43
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$36.96
|
| Rate for Payer: UHCCP Medicaid |
$24.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.43
|
|
|
PROLONG NURSING FAC EVAL 15M
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS G0317
|
| Hospital Charge Code |
51000345
|
|
Hospital Revenue Code
|
524
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
PROLONG SERVICE W/O CONTACT
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS 99358
|
| Hospital Charge Code |
51000347
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem Medicaid |
$85.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Humana KY Medicaid |
$85.97
|
| Rate for Payer: Kentucky WC Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
PROLONG SERVICE W/O CONTACT
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 99358
|
| Hospital Charge Code |
51000347
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Aetna Commercial |
$167.25
|
| Rate for Payer: Anthem Medicaid |
$105.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$144.79
|
| Rate for Payer: Healthspan PPO |
$124.33
|
| Rate for Payer: Humana Medicaid |
$105.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$147.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.10
|
| Rate for Payer: Molina Healthcare Passport |
$105.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.05
|
|
|
PROLONG SERVICE W/O CONTACT
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS 99358
|
| Hospital Charge Code |
51000347
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
PROLONG SERV W/O CONTACT ADD
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS 99359
|
| Hospital Charge Code |
51000348
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
PROLONG SERV W/O CONTACT ADD
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 99359
|
| Hospital Charge Code |
51000348
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.32 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$80.38
|
| Rate for Payer: Anthem Medicaid |
$51.32
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$69.73
|
| Rate for Payer: Healthspan PPO |
$59.75
|
| Rate for Payer: Humana Medicaid |
$51.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.35
|
| Rate for Payer: Molina Healthcare Passport |
$51.32
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.83
|
|
|
PROLONG SERV W/O CONTACT ADD
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS 99359
|
| Hospital Charge Code |
51000348
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem Medicaid |
$68.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Humana KY Medicaid |
$68.78
|
| Rate for Payer: Kentucky WC Medicaid |
$69.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
PROMETHAZINE 12.5MG/10ML ELIX
|
Facility
|
IP
|
$4.77
|
|
|
Service Code
|
NDC 27808005102
|
| Hospital Charge Code |
25001252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.96
|
| Rate for Payer: First Health Commercial |
$4.53
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.20
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.29
|
| Rate for Payer: PHCS Commercial |
$4.58
|
| Rate for Payer: United Healthcare All Payer |
$4.20
|
|
|
PROMETHAZINE 12.5MG/10ML ELIX
|
Facility
|
OP
|
$4.77
|
|
|
Service Code
|
NDC 27808005102
|
| Hospital Charge Code |
25001252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.96
|
| Rate for Payer: First Health Commercial |
$4.53
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.20
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.29
|
| Rate for Payer: PHCS Commercial |
$4.58
|
| Rate for Payer: United Healthcare All Payer |
$4.20
|
|
|
PROMETRIUM(PROGESTERON3)100MGC
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 70700016201
|
| Hospital Charge Code |
25001253
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
PROMETRIUM(PROGESTERON3)100MGC
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 70700016201
|
| Hospital Charge Code |
25001253
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
PROMODEL ORTHOBIOLGC IMPT 10CC
|
Facility
|
IP
|
$12,010.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,603.22 |
| Max. Negotiated Rate |
$11,530.30 |
| Rate for Payer: Aetna Commercial |
$9,248.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,368.37
|
| Rate for Payer: Cash Price |
$6,005.36
|
| Rate for Payer: Cigna Commercial |
$9,968.91
|
| Rate for Payer: First Health Commercial |
$11,410.19
|
| Rate for Payer: Humana Commercial |
$10,209.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,848.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,863.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,603.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,569.44
|
| Rate for Payer: Ohio Health Group HMO |
$9,008.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,608.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,449.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,287.40
|
| Rate for Payer: PHCS Commercial |
$11,530.30
|
| Rate for Payer: United Healthcare All Payer |
$10,569.44
|
|
|
PROMODEL ORTHOBIOLGC IMPT 10CC
|
Facility
|
OP
|
$12,010.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,603.22 |
| Max. Negotiated Rate |
$11,530.30 |
| Rate for Payer: Aetna Commercial |
$9,248.26
|
| Rate for Payer: Anthem Medicaid |
$4,130.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,368.37
|
| Rate for Payer: Cash Price |
$6,005.36
|
| Rate for Payer: Cigna Commercial |
$9,968.91
|
| Rate for Payer: First Health Commercial |
$11,410.19
|
| Rate for Payer: Humana Commercial |
$10,209.12
|
| Rate for Payer: Humana KY Medicaid |
$4,130.49
|
| Rate for Payer: Kentucky WC Medicaid |
$4,172.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,848.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,863.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,603.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,213.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,569.44
|
| Rate for Payer: Ohio Health Group HMO |
$9,008.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,608.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,449.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,287.40
|
| Rate for Payer: PHCS Commercial |
$11,530.30
|
| Rate for Payer: United Healthcare All Payer |
$10,569.44
|
|
|
PROMODEL ORTHOBIOLOGC IMPT 5CC
|
Facility
|
OP
|
$7,263.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.96 |
| Max. Negotiated Rate |
$6,972.67 |
| Rate for Payer: Aetna Commercial |
$5,592.66
|
| Rate for Payer: Anthem Medicaid |
$2,497.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,665.30
|
| Rate for Payer: Cash Price |
$3,631.60
|
| Rate for Payer: Cigna Commercial |
$6,028.46
|
| Rate for Payer: First Health Commercial |
$6,900.04
|
| Rate for Payer: Humana Commercial |
$6,173.72
|
| Rate for Payer: Humana KY Medicaid |
$2,497.81
|
| Rate for Payer: Kentucky WC Medicaid |
$2,523.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,955.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,360.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,178.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,547.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,391.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,447.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,810.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,318.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,011.61
|
| Rate for Payer: PHCS Commercial |
$6,972.67
|
| Rate for Payer: United Healthcare All Payer |
$6,391.62
|
|
|
PROMODEL ORTHOBIOLOGC IMPT 5CC
|
Facility
|
IP
|
$7,263.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.96 |
| Max. Negotiated Rate |
$6,972.67 |
| Rate for Payer: Aetna Commercial |
$5,592.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,665.30
|
| Rate for Payer: Cash Price |
$3,631.60
|
| Rate for Payer: Cigna Commercial |
$6,028.46
|
| Rate for Payer: First Health Commercial |
$6,900.04
|
| Rate for Payer: Humana Commercial |
$6,173.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,955.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,360.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,178.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,391.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,447.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,810.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,318.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,011.61
|
| Rate for Payer: PHCS Commercial |
$6,972.67
|
| Rate for Payer: United Healthcare All Payer |
$6,391.62
|
|
|
PROMODEL ORTHOBIOLOGC INJ 10CC
|
Facility
|
OP
|
$12,010.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,603.22 |
| Max. Negotiated Rate |
$11,530.30 |
| Rate for Payer: Aetna Commercial |
$9,248.26
|
| Rate for Payer: Anthem Medicaid |
$4,130.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,368.37
|
| Rate for Payer: Cash Price |
$6,005.36
|
| Rate for Payer: Cigna Commercial |
$9,968.91
|
| Rate for Payer: First Health Commercial |
$11,410.19
|
| Rate for Payer: Humana Commercial |
$10,209.12
|
| Rate for Payer: Humana KY Medicaid |
$4,130.49
|
| Rate for Payer: Kentucky WC Medicaid |
$4,172.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,848.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,863.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,603.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,213.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,569.44
|
| Rate for Payer: Ohio Health Group HMO |
$9,008.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,608.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,449.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,287.40
|
| Rate for Payer: PHCS Commercial |
$11,530.30
|
| Rate for Payer: United Healthcare All Payer |
$10,569.44
|
|
|
PROMODEL ORTHOBIOLOGC INJ 10CC
|
Facility
|
IP
|
$12,010.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,603.22 |
| Max. Negotiated Rate |
$11,530.30 |
| Rate for Payer: Aetna Commercial |
$9,248.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,368.37
|
| Rate for Payer: Cash Price |
$6,005.36
|
| Rate for Payer: Cigna Commercial |
$9,968.91
|
| Rate for Payer: First Health Commercial |
$11,410.19
|
| Rate for Payer: Humana Commercial |
$10,209.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,848.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,863.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,603.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,569.44
|
| Rate for Payer: Ohio Health Group HMO |
$9,008.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,608.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,449.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,287.40
|
| Rate for Payer: PHCS Commercial |
$11,530.30
|
| Rate for Payer: United Healthcare All Payer |
$10,569.44
|
|
|
PROMODEL ORTHOBIOLOGIC INJ 5CC
|
Facility
|
OP
|
$7,263.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.96 |
| Max. Negotiated Rate |
$6,972.67 |
| Rate for Payer: Aetna Commercial |
$5,592.66
|
| Rate for Payer: Anthem Medicaid |
$2,497.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,665.30
|
| Rate for Payer: Cash Price |
$3,631.60
|
| Rate for Payer: Cigna Commercial |
$6,028.46
|
| Rate for Payer: First Health Commercial |
$6,900.04
|
| Rate for Payer: Humana Commercial |
$6,173.72
|
| Rate for Payer: Humana KY Medicaid |
$2,497.81
|
| Rate for Payer: Kentucky WC Medicaid |
$2,523.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,955.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,360.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,178.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,547.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,391.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,447.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,810.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,318.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,011.61
|
| Rate for Payer: PHCS Commercial |
$6,972.67
|
| Rate for Payer: United Healthcare All Payer |
$6,391.62
|
|
