|
PROTEUS SP ATPD GENE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$20.05
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$20.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
PROTEUS SP ATPD GENE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
PROTHROMBIN-INR
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS 85610
|
| Hospital Charge Code |
30000618
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Ambetter Exchange |
$4.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.15
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$5.37
|
| Rate for Payer: Healthspan PPO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.29
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.58
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.29
|
|
|
PROTHROMBIN-INR
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS 85610
|
| Hospital Charge Code |
30000618
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$4.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.29
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$4.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.29
|
| Rate for Payer: Kentucky WC Medicaid |
$4.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
PROTHROMBIN-INR
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS 85610
|
| Hospital Charge Code |
30000618
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36.13
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
PROTHROMBIN TIME;
|
Facility
|
OP
|
$6.01
|
|
|
Service Code
|
CPT 85610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.79
|
| Rate for Payer: Humana Medicare Advantage |
$4.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.15
|
|
|
PROTONIX 20MG TABLET
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 60687072501
|
| Hospital Charge Code |
25001260
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PROTONIX 20MG TABLET
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 60687072501
|
| Hospital Charge Code |
25001260
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PROTONIX (GEN) 40MG IVP
|
Facility
|
IP
|
$112.08
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
25003391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$107.60 |
| Rate for Payer: Aetna Commercial |
$86.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.42
|
| Rate for Payer: Cash Price |
$56.04
|
| Rate for Payer: Cigna Commercial |
$93.03
|
| Rate for Payer: First Health Commercial |
$106.48
|
| Rate for Payer: Humana Commercial |
$95.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.63
|
| Rate for Payer: Ohio Health Group HMO |
$84.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.34
|
| Rate for Payer: PHCS Commercial |
$107.60
|
| Rate for Payer: United Healthcare All Payer |
$98.63
|
|
|
PROTONIX (GEN) 40MG IVP
|
Facility
|
OP
|
$112.08
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
25003391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$107.60 |
| Rate for Payer: Aetna Commercial |
$86.30
|
| Rate for Payer: Anthem Medicaid |
$38.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.42
|
| Rate for Payer: Cash Price |
$56.04
|
| Rate for Payer: Cigna Commercial |
$93.03
|
| Rate for Payer: First Health Commercial |
$106.48
|
| Rate for Payer: Humana Commercial |
$95.27
|
| Rate for Payer: Humana KY Medicaid |
$38.54
|
| Rate for Payer: Kentucky WC Medicaid |
$38.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.63
|
| Rate for Payer: Ohio Health Group HMO |
$84.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.34
|
| Rate for Payer: PHCS Commercial |
$107.60
|
| Rate for Payer: United Healthcare All Payer |
$98.63
|
|
|
PROTONIX (PANTOPRAZOLE) 40MG
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003390
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
PROTONIX (PANTOPRAZOLE) 40MG
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003390
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$23.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$23.04
|
| Rate for Payer: Kentucky WC Medicaid |
$23.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
PROTONIX(PANTOPRAZO SOD)40MG T
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 60687073601
|
| Hospital Charge Code |
25001261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
PROTONIX(PANTOPRAZO SOD)40MG T
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 60687073601
|
| Hospital Charge Code |
25001261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
PROTOPAMPRALIDOXIMECHLORIDE1GM
|
Facility
|
OP
|
$355.70
|
|
|
Service Code
|
HCPCS J2730
|
| Hospital Charge Code |
25002333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.71 |
| Max. Negotiated Rate |
$341.47 |
| Rate for Payer: Aetna Commercial |
$273.89
|
| Rate for Payer: Anthem Medicaid |
$122.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.45
|
| Rate for Payer: Cash Price |
$177.85
|
| Rate for Payer: Cigna Commercial |
$295.23
|
| Rate for Payer: First Health Commercial |
$337.92
|
| Rate for Payer: Humana Commercial |
$302.35
|
| Rate for Payer: Humana KY Medicaid |
$122.33
|
| Rate for Payer: Kentucky WC Medicaid |
$123.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$262.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$313.02
|
| Rate for Payer: Ohio Health Group HMO |
$266.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$309.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.43
|
| Rate for Payer: PHCS Commercial |
$341.47
|
| Rate for Payer: United Healthcare All Payer |
$313.02
|
|
|
PROTOPAMPRALIDOXIMECHLORIDE1GM
|
Facility
|
IP
|
$355.70
|
|
|
Service Code
|
HCPCS J2730
|
| Hospital Charge Code |
25002333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.71 |
| Max. Negotiated Rate |
$341.47 |
| Rate for Payer: Aetna Commercial |
$273.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.45
|
| Rate for Payer: Cash Price |
$177.85
|
| Rate for Payer: Cigna Commercial |
$295.23
|
| Rate for Payer: First Health Commercial |
$337.92
|
| Rate for Payer: Humana Commercial |
$302.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$262.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$313.02
|
| Rate for Payer: Ohio Health Group HMO |
$266.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$309.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.43
|
| Rate for Payer: PHCS Commercial |
$341.47
|
| Rate for Payer: United Healthcare All Payer |
$313.02
|
|
|
PROTOPIC(TACROLIMUS)ONT.1%30GR
|
Facility
|
OP
|
$11.17
|
|
|
Service Code
|
NDC 68462053435
|
| Hospital Charge Code |
25001262
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$10.72 |
| Rate for Payer: Aetna Commercial |
$8.60
|
| Rate for Payer: Anthem Medicaid |
$3.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.71
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.27
|
| Rate for Payer: First Health Commercial |
$10.61
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Humana KY Medicaid |
$3.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.83
|
| Rate for Payer: Ohio Health Group HMO |
$8.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.71
|
| Rate for Payer: PHCS Commercial |
$10.72
|
| Rate for Payer: United Healthcare All Payer |
$9.83
|
|
|
PROTOPIC(TACROLIMUS)ONT.1%30GR
|
Facility
|
IP
|
$11.17
|
|
|
Service Code
|
NDC 68462053435
|
| Hospital Charge Code |
25001262
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$10.72 |
| Rate for Payer: Aetna Commercial |
$8.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.71
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.27
|
| Rate for Payer: First Health Commercial |
$10.61
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.83
|
| Rate for Payer: Ohio Health Group HMO |
$8.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.71
|
| Rate for Payer: PHCS Commercial |
$10.72
|
| Rate for Payer: United Healthcare All Payer |
$9.83
|
|
|
PROTRUSIO CAGES 48*45 L
|
Facility
|
IP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
|
PROTRUSIO CAGES 48*45 L
|
Facility
|
OP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem Medicaid |
$3,872.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Humana KY Medicaid |
$3,872.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3,912.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,950.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
|
PROTRUSIO CAGES 48*45 R
|
Facility
|
IP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
|
PROTRUSIO CAGES 48*45 R
|
Facility
|
OP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem Medicaid |
$3,872.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Humana KY Medicaid |
$3,872.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3,912.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,950.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
|
PROTRUSIO CAGES 52*49 L
|
Facility
|
IP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
|
PROTRUSIO CAGES 52*49 L
|
Facility
|
OP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem Medicaid |
$3,872.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Humana KY Medicaid |
$3,872.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3,912.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,950.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
|
PROTRUSIO CAGES 52*49 R
|
Facility
|
IP
|
$11,260.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,378.28 |
| Max. Negotiated Rate |
$10,810.51 |
| Rate for Payer: Aetna Commercial |
$8,670.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,783.54
|
| Rate for Payer: Cash Price |
$5,630.47
|
| Rate for Payer: Cigna Commercial |
$9,346.59
|
| Rate for Payer: First Health Commercial |
$10,697.90
|
| Rate for Payer: Humana Commercial |
$9,571.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,233.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,310.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,378.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,909.64
|
| Rate for Payer: Ohio Health Group HMO |
$8,445.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,008.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,797.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,770.06
|
| Rate for Payer: PHCS Commercial |
$10,810.51
|
| Rate for Payer: United Healthcare All Payer |
$9,909.64
|
|
