|
PROVENGE 50 MM/250 PER INFSN
|
Facility
|
OP
|
$62,740.52
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
25002716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21,576.46 |
| Max. Negotiated Rate |
$78,324.36 |
| Rate for Payer: Aetna Commercial |
$48,310.20
|
| Rate for Payer: Anthem Medicaid |
$21,576.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$55,945.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48,937.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78,324.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$75,527.06
|
| Rate for Payer: Cash Price |
$31,370.26
|
| Rate for Payer: Cash Price |
$31,370.26
|
| Rate for Payer: Cigna Commercial |
$52,074.63
|
| Rate for Payer: First Health Commercial |
$59,603.49
|
| Rate for Payer: Humana Commercial |
$53,329.44
|
| Rate for Payer: Humana KY Medicaid |
$21,576.46
|
| Rate for Payer: Humana Medicare Advantage |
$55,945.97
|
| Rate for Payer: Kentucky WC Medicaid |
$21,796.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51,447.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,302.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67,135.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,009.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,211.66
|
| Rate for Payer: Ohio Health Group HMO |
$47,055.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50,192.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54,584.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43,290.96
|
| Rate for Payer: PHCS Commercial |
$60,230.90
|
| Rate for Payer: United Healthcare All Payer |
$55,211.66
|
|
|
PROVENGE 50 MM/250 PER INFSN
|
Facility
|
IP
|
$62,740.52
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
25002716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,822.16 |
| Max. Negotiated Rate |
$60,230.90 |
| Rate for Payer: Aetna Commercial |
$48,310.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48,937.61
|
| Rate for Payer: Cash Price |
$31,370.26
|
| Rate for Payer: Cigna Commercial |
$52,074.63
|
| Rate for Payer: First Health Commercial |
$59,603.49
|
| Rate for Payer: Humana Commercial |
$53,329.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51,447.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,302.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,822.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,211.66
|
| Rate for Payer: Ohio Health Group HMO |
$47,055.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50,192.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54,584.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43,290.96
|
| Rate for Payer: PHCS Commercial |
$60,230.90
|
| Rate for Payer: United Healthcare All Payer |
$55,211.66
|
|
|
PROVENTIL(ALBUTEROL) 2 2MG/5ML
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 70752010212
|
| Hospital Charge Code |
25001265
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
PROVENTIL(ALBUTEROL) 2 2MG/5ML
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 70752010212
|
| Hospital Charge Code |
25001265
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
PROVENTIL (ALBUTEROL) 2MG/1TAB
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 70710106101
|
| Hospital Charge Code |
25001264
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
PROVENTIL (ALBUTEROL) 2MG/1TAB
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 70710106101
|
| Hospital Charge Code |
25001264
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
PROVENTILHFA 200puff/6.7gm MDI
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
NDC 60687066291
|
| Hospital Charge Code |
25004039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$168.96 |
| Rate for Payer: Aetna Commercial |
$135.52
|
| Rate for Payer: Anthem Medicaid |
$60.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$137.28
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$146.08
|
| Rate for Payer: First Health Commercial |
$167.20
|
| Rate for Payer: Humana Commercial |
$149.60
|
| Rate for Payer: Humana KY Medicaid |
$60.53
|
| Rate for Payer: Kentucky WC Medicaid |
$61.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$144.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$61.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.88
|
| Rate for Payer: Ohio Health Group HMO |
$132.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.44
|
| Rate for Payer: PHCS Commercial |
$168.96
|
| Rate for Payer: United Healthcare All Payer |
$154.88
|
|
|
PROVENTILHFA 200puff/6.7gm MDI
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
NDC 60687066291
|
| Hospital Charge Code |
25004039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$168.96 |
| Rate for Payer: Aetna Commercial |
$135.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$137.28
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$146.08
|
| Rate for Payer: First Health Commercial |
$167.20
|
| Rate for Payer: Humana Commercial |
$149.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$144.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.88
|
| Rate for Payer: Ohio Health Group HMO |
$132.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.44
|
| Rate for Payer: PHCS Commercial |
$168.96
|
| Rate for Payer: United Healthcare All Payer |
$154.88
|
|
|
PROVERA(MEDROXYPROG 2.5MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 59762005501
|
| Hospital Charge Code |
25001267
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PROVERA(MEDROXYPROG 2.5MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 59762005501
|
| Hospital Charge Code |
25001267
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PROVIGIL (MODAFINIL)100 MG TAB
|
Facility
|
OP
|
$60.97
|
|
|
Service Code
|
NDC 60505252603
|
| Hospital Charge Code |
25001268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$58.53 |
| Rate for Payer: Aetna Commercial |
$46.95
|
| Rate for Payer: Anthem Medicaid |
$20.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.56
|
| Rate for Payer: Cash Price |
$30.48
|
| Rate for Payer: Cigna Commercial |
$50.61
|
| Rate for Payer: First Health Commercial |
$57.92
|
| Rate for Payer: Humana Commercial |
$51.82
|
| Rate for Payer: Humana KY Medicaid |
$20.97
|
| Rate for Payer: Kentucky WC Medicaid |
$21.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.65
|
| Rate for Payer: Ohio Health Group HMO |
$45.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.07
|
| Rate for Payer: PHCS Commercial |
$58.53
|
| Rate for Payer: United Healthcare All Payer |
$53.65
|
|
|
PROVIGIL (MODAFINIL)100 MG TAB
|
Facility
|
IP
|
$60.97
|
|
|
Service Code
|
NDC 60505252603
|
| Hospital Charge Code |
25001268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$58.53 |
| Rate for Payer: Aetna Commercial |
$46.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.56
|
| Rate for Payer: Cash Price |
$30.48
|
| Rate for Payer: Cigna Commercial |
$50.61
|
| Rate for Payer: First Health Commercial |
$57.92
|
| Rate for Payer: Humana Commercial |
$51.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.65
|
| Rate for Payer: Ohio Health Group HMO |
$45.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.07
|
| Rate for Payer: PHCS Commercial |
$58.53
|
| Rate for Payer: United Healthcare All Payer |
$53.65
|
|
|
PROVISC(SOD.HYALUR 10MG/.85ML
|
Facility
|
IP
|
$614.91
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
25003393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.47 |
| Max. Negotiated Rate |
$590.31 |
| Rate for Payer: Aetna Commercial |
$473.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$479.63
|
| Rate for Payer: Cash Price |
$307.46
|
| Rate for Payer: Cigna Commercial |
$510.38
|
| Rate for Payer: First Health Commercial |
$584.16
|
| Rate for Payer: Humana Commercial |
$522.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$504.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$453.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$184.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$541.12
|
| Rate for Payer: Ohio Health Group HMO |
$461.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$491.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$534.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$424.29
|
| Rate for Payer: PHCS Commercial |
$590.31
|
| Rate for Payer: United Healthcare All Payer |
$541.12
|
|
|
PROVISC(SOD.HYALUR 10MG/.85ML
|
Facility
|
OP
|
$614.91
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
25003393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.47 |
| Max. Negotiated Rate |
$590.31 |
| Rate for Payer: Aetna Commercial |
$473.48
|
| Rate for Payer: Anthem Medicaid |
$211.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$479.63
|
| Rate for Payer: Cash Price |
$307.46
|
| Rate for Payer: Cigna Commercial |
$510.38
|
| Rate for Payer: First Health Commercial |
$584.16
|
| Rate for Payer: Humana Commercial |
$522.67
|
| Rate for Payer: Humana KY Medicaid |
$211.47
|
| Rate for Payer: Kentucky WC Medicaid |
$213.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$504.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$453.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$184.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$215.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$541.12
|
| Rate for Payer: Ohio Health Group HMO |
$461.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$491.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$534.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$424.29
|
| Rate for Payer: PHCS Commercial |
$590.31
|
| Rate for Payer: United Healthcare All Payer |
$541.12
|
|
|
PROVOCHOLINE(METHACHOLI) 1MG
|
Facility
|
IP
|
$144.04
|
|
|
Service Code
|
HCPCS J7674
|
| Hospital Charge Code |
25002519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.21 |
| Max. Negotiated Rate |
$138.28 |
| Rate for Payer: Aetna Commercial |
$110.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.35
|
| Rate for Payer: Cash Price |
$72.02
|
| Rate for Payer: Cigna Commercial |
$119.55
|
| Rate for Payer: First Health Commercial |
$136.84
|
| Rate for Payer: Humana Commercial |
$122.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.76
|
| Rate for Payer: Ohio Health Group HMO |
$108.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.39
|
| Rate for Payer: PHCS Commercial |
$138.28
|
| Rate for Payer: United Healthcare All Payer |
$126.76
|
|
|
PROVOCHOLINE(METHACHOLI) 1MG
|
Facility
|
OP
|
$144.04
|
|
|
Service Code
|
HCPCS J7674
|
| Hospital Charge Code |
25002519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.21 |
| Max. Negotiated Rate |
$138.28 |
| Rate for Payer: Aetna Commercial |
$110.91
|
| Rate for Payer: Anthem Medicaid |
$49.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.35
|
| Rate for Payer: Cash Price |
$72.02
|
| Rate for Payer: Cigna Commercial |
$119.55
|
| Rate for Payer: First Health Commercial |
$136.84
|
| Rate for Payer: Humana Commercial |
$122.43
|
| Rate for Payer: Humana KY Medicaid |
$49.54
|
| Rate for Payer: Kentucky WC Medicaid |
$50.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.76
|
| Rate for Payer: Ohio Health Group HMO |
$108.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.39
|
| Rate for Payer: PHCS Commercial |
$138.28
|
| Rate for Payer: United Healthcare All Payer |
$126.76
|
|
|
PROWATER PTCA GW 180CM
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
PROWATER PTCA GW 180CM
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
PROX REAMING GUIDE
|
Facility
|
OP
|
$3,057.50
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$917.25 |
| Max. Negotiated Rate |
$2,935.20 |
| Rate for Payer: Aetna Commercial |
$2,354.28
|
| Rate for Payer: Anthem Medicaid |
$1,051.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,384.85
|
| Rate for Payer: Cash Price |
$1,528.75
|
| Rate for Payer: Cigna Commercial |
$2,537.72
|
| Rate for Payer: First Health Commercial |
$2,904.62
|
| Rate for Payer: Humana Commercial |
$2,598.88
|
| Rate for Payer: Humana KY Medicaid |
$1,051.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,062.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,507.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,256.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$917.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,072.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,690.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,293.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,446.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,660.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,109.68
|
| Rate for Payer: PHCS Commercial |
$2,935.20
|
| Rate for Payer: United Healthcare All Payer |
$2,690.60
|
|
|
PROX REAMING GUIDE
|
Facility
|
IP
|
$3,057.50
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$917.25 |
| Max. Negotiated Rate |
$2,935.20 |
| Rate for Payer: Aetna Commercial |
$2,354.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,384.85
|
| Rate for Payer: Cash Price |
$1,528.75
|
| Rate for Payer: Cigna Commercial |
$2,537.72
|
| Rate for Payer: First Health Commercial |
$2,904.62
|
| Rate for Payer: Humana Commercial |
$2,598.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,507.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,256.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$917.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,690.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,293.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,446.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,660.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,109.68
|
| Rate for Payer: PHCS Commercial |
$2,935.20
|
| Rate for Payer: United Healthcare All Payer |
$2,690.60
|
|
|
PROX TIBA LK PL3.5*4HL LFT
|
Facility
|
IP
|
$6,854.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,056.32 |
| Max. Negotiated Rate |
$6,580.22 |
| Rate for Payer: Aetna Commercial |
$5,277.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,346.43
|
| Rate for Payer: Cash Price |
$3,427.20
|
| Rate for Payer: Cigna Commercial |
$5,689.15
|
| Rate for Payer: First Health Commercial |
$6,511.68
|
| Rate for Payer: Humana Commercial |
$5,826.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,620.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,058.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,056.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,031.87
|
| Rate for Payer: Ohio Health Group HMO |
$5,140.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,483.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,963.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,729.54
|
| Rate for Payer: PHCS Commercial |
$6,580.22
|
| Rate for Payer: United Healthcare All Payer |
$6,031.87
|
|
|
PROX TIBA LK PL3.5*4HL LFT
|
Facility
|
OP
|
$6,854.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,056.32 |
| Max. Negotiated Rate |
$6,580.22 |
| Rate for Payer: Aetna Commercial |
$5,277.89
|
| Rate for Payer: Anthem Medicaid |
$2,357.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,346.43
|
| Rate for Payer: Cash Price |
$3,427.20
|
| Rate for Payer: Cigna Commercial |
$5,689.15
|
| Rate for Payer: First Health Commercial |
$6,511.68
|
| Rate for Payer: Humana Commercial |
$5,826.24
|
| Rate for Payer: Humana KY Medicaid |
$2,357.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,381.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,620.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,058.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,056.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,404.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,031.87
|
| Rate for Payer: Ohio Health Group HMO |
$5,140.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,483.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,963.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,729.54
|
| Rate for Payer: PHCS Commercial |
$6,580.22
|
| Rate for Payer: United Healthcare All Payer |
$6,031.87
|
|
|
PROZAC (FLUOXETINE) 20MG/1CAP
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 68001040000
|
| Hospital Charge Code |
25001270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PROZAC (FLUOXETINE) 20MG/1CAP
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 68001040000
|
| Hospital Charge Code |
25001270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
PROZAC (FLUOXETINE) 2 20MG/5ML
|
Facility
|
IP
|
$10.88
|
|
|
Service Code
|
NDC 54838052340
|
| Hospital Charge Code |
25001271
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.03
|
| Rate for Payer: First Health Commercial |
$10.34
|
| Rate for Payer: Humana Commercial |
$9.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.57
|
| Rate for Payer: Ohio Health Group HMO |
$8.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.51
|
| Rate for Payer: PHCS Commercial |
$10.44
|
| Rate for Payer: United Healthcare All Payer |
$9.57
|
|
