|
BEHAVIOR ID ASSMNT BY A PHYS(T
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS 97151
|
| Hospital Charge Code |
900T0019
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna Commercial |
$30.03
|
| Rate for Payer: Anthem Medicaid |
$13.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$77.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$107.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$104.06
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$32.37
|
| Rate for Payer: First Health Commercial |
$37.05
|
| Rate for Payer: Humana Commercial |
$33.15
|
| Rate for Payer: Humana KY Medicaid |
$13.41
|
| Rate for Payer: Humana Medicare Advantage |
$77.08
|
| Rate for Payer: Kentucky WC Medicaid |
$13.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.32
|
| Rate for Payer: Ohio Health Group HMO |
$29.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.09
|
| Rate for Payer: PHCS Commercial |
$37.44
|
| Rate for Payer: United Healthcare All Payer |
$34.32
|
|
|
BEHAV QUAL VOICE RES ANALYSIS
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
HCPCS 92524
|
| Hospital Charge Code |
44000006
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$32.37 |
| Max. Negotiated Rate |
$239.04 |
| Rate for Payer: Aetna Commercial |
$191.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$194.22
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$206.67
|
| Rate for Payer: First Health Commercial |
$236.55
|
| Rate for Payer: Humana Commercial |
$211.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$204.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$183.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$219.12
|
| Rate for Payer: Ohio Health Group HMO |
$186.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.19
|
| Rate for Payer: PHCS Commercial |
$239.04
|
| Rate for Payer: United Healthcare All Payer |
$219.12
|
|
|
BEHAV QUAL VOICE RES ANALYSIS
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
HCPCS 92524
|
| Hospital Charge Code |
44000006
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$32.37 |
| Max. Negotiated Rate |
$239.04 |
| Rate for Payer: Aetna Commercial |
$191.73
|
| Rate for Payer: Anthem Medicaid |
$85.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$194.22
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$206.67
|
| Rate for Payer: First Health Commercial |
$236.55
|
| Rate for Payer: Humana Commercial |
$211.65
|
| Rate for Payer: Humana KY Medicaid |
$85.63
|
| Rate for Payer: Kentucky WC Medicaid |
$86.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$204.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$183.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$219.12
|
| Rate for Payer: Ohio Health Group HMO |
$186.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.19
|
| Rate for Payer: PHCS Commercial |
$239.04
|
| Rate for Payer: United Healthcare All Payer |
$219.12
|
|
|
BELATACEPT 1mg (250mg SDV)
|
Facility
|
OP
|
$5,285.85
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
25004471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$5,074.42 |
| Rate for Payer: Aetna Commercial |
$4,070.10
|
| Rate for Payer: Anthem Medicaid |
$1,817.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,122.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.23
|
| Rate for Payer: Cash Price |
$2,642.93
|
| Rate for Payer: Cash Price |
$2,642.93
|
| Rate for Payer: Cigna Commercial |
$4,387.26
|
| Rate for Payer: First Health Commercial |
$5,021.56
|
| Rate for Payer: Humana Commercial |
$4,492.97
|
| Rate for Payer: Humana KY Medicaid |
$1,817.80
|
| Rate for Payer: Humana Medicare Advantage |
$3.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1,836.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,334.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,900.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,854.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,651.55
|
| Rate for Payer: Ohio Health Group HMO |
$3,964.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,057.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,638.61
|
| Rate for Payer: PHCS Commercial |
$5,074.42
|
| Rate for Payer: United Healthcare All Payer |
$4,651.55
|
|
|
BELATACEPT 1mg (250mg SDV)
|
Facility
|
IP
|
$5,285.85
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
25004471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$687.16 |
| Max. Negotiated Rate |
$5,074.42 |
| Rate for Payer: Aetna Commercial |
$4,070.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,122.96
|
| Rate for Payer: Cash Price |
$2,642.93
|
| Rate for Payer: Cigna Commercial |
$4,387.26
|
| Rate for Payer: First Health Commercial |
$5,021.56
|
| Rate for Payer: Humana Commercial |
$4,492.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,334.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,900.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,585.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,651.55
|
| Rate for Payer: Ohio Health Group HMO |
$3,964.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,057.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,638.61
|
| Rate for Payer: PHCS Commercial |
$5,074.42
|
| Rate for Payer: United Healthcare All Payer |
$4,651.55
|
|
|
BENADRYL 12.5MG/5ML ELIXIR
|
Facility
|
OP
|
$3.98
|
|
|
Service Code
|
NDC 121048900
|
| Hospital Charge Code |
25000315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Anthem Medicaid |
$1.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.10
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Cigna Commercial |
$3.30
|
| Rate for Payer: First Health Commercial |
$3.78
|
| Rate for Payer: Humana Commercial |
$3.38
|
| Rate for Payer: Humana KY Medicaid |
$1.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.50
|
| Rate for Payer: Ohio Health Group HMO |
$2.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.23
|
| Rate for Payer: PHCS Commercial |
$3.82
|
| Rate for Payer: United Healthcare All Payer |
$3.50
|
|
|
BENADRYL 12.5MG/5ML ELIXIR
|
Facility
|
IP
|
$3.98
|
|
|
Service Code
|
NDC 121048900
|
| Hospital Charge Code |
25000315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.10
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Cigna Commercial |
$3.30
|
| Rate for Payer: First Health Commercial |
$3.78
|
| Rate for Payer: Humana Commercial |
$3.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.50
|
| Rate for Payer: Ohio Health Group HMO |
$2.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.23
|
| Rate for Payer: PHCS Commercial |
$3.82
|
| Rate for Payer: United Healthcare All Payer |
$3.50
|
|
|
BENADRYL(DIPHENHYDRA 25MG/1TAB
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
25000316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Anthem Medicaid |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.19
|
| Rate for Payer: First Health Commercial |
$0.22
|
| Rate for Payer: Humana Commercial |
$0.20
|
| Rate for Payer: Humana KY Medicaid |
$0.08
|
| Rate for Payer: Kentucky WC Medicaid |
$0.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.20
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
BENADRYL(DIPHENHYDRA 25MG/1TAB
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
25000316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.19
|
| Rate for Payer: First Health Commercial |
$0.22
|
| Rate for Payer: Humana Commercial |
$0.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.20
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
BENADRYL(DIPHENHYDRA 50MG/1CAP
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
25002705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
BENADRYL(DIPHENHYDRA 50MG/1CAP
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
25002705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
OP
|
$74.07
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
63600031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$71.11 |
| Rate for Payer: Aetna Commercial |
$57.03
|
| Rate for Payer: Anthem Medicaid |
$25.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.77
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cigna Commercial |
$61.48
|
| Rate for Payer: First Health Commercial |
$70.37
|
| Rate for Payer: Humana Commercial |
$62.96
|
| Rate for Payer: Humana KY Medicaid |
$25.47
|
| Rate for Payer: Kentucky WC Medicaid |
$25.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.18
|
| Rate for Payer: Ohio Health Group HMO |
$55.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.96
|
| Rate for Payer: PHCS Commercial |
$71.11
|
| Rate for Payer: United Healthcare All Payer |
$65.18
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
OP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
25002034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$74.08 |
| Rate for Payer: Aetna Commercial |
$59.42
|
| Rate for Payer: Anthem Medicaid |
$26.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.19
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cigna Commercial |
$64.05
|
| Rate for Payer: First Health Commercial |
$73.31
|
| Rate for Payer: Humana Commercial |
$65.59
|
| Rate for Payer: Humana KY Medicaid |
$26.54
|
| Rate for Payer: Kentucky WC Medicaid |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.91
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.92
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
OP
|
$74.07
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
636T0031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$71.11 |
| Rate for Payer: Aetna Commercial |
$57.03
|
| Rate for Payer: Anthem Medicaid |
$25.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.77
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cigna Commercial |
$61.48
|
| Rate for Payer: First Health Commercial |
$70.37
|
| Rate for Payer: Humana Commercial |
$62.96
|
| Rate for Payer: Humana KY Medicaid |
$25.47
|
| Rate for Payer: Kentucky WC Medicaid |
$25.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.18
|
| Rate for Payer: Ohio Health Group HMO |
$55.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.96
|
| Rate for Payer: PHCS Commercial |
$71.11
|
| Rate for Payer: United Healthcare All Payer |
$65.18
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
IP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
25002034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$74.08 |
| Rate for Payer: Aetna Commercial |
$59.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.19
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cigna Commercial |
$64.05
|
| Rate for Payer: First Health Commercial |
$73.31
|
| Rate for Payer: Humana Commercial |
$65.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.91
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.92
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
IP
|
$74.07
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
636T0031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$71.11 |
| Rate for Payer: Aetna Commercial |
$57.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.77
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cigna Commercial |
$61.48
|
| Rate for Payer: First Health Commercial |
$70.37
|
| Rate for Payer: Humana Commercial |
$62.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.18
|
| Rate for Payer: Ohio Health Group HMO |
$55.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.96
|
| Rate for Payer: PHCS Commercial |
$71.11
|
| Rate for Payer: United Healthcare All Payer |
$65.18
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Professional
|
Both
|
$74.07
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
63600031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$74.07 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.07
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.46
|
| Rate for Payer: Multiplan PHCS |
$44.44
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.85
|
| Rate for Payer: UHCCP Medicaid |
$25.92
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
IP
|
$74.07
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
63600031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$71.11 |
| Rate for Payer: Aetna Commercial |
$57.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.77
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cigna Commercial |
$61.48
|
| Rate for Payer: First Health Commercial |
$70.37
|
| Rate for Payer: Humana Commercial |
$62.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.18
|
| Rate for Payer: Ohio Health Group HMO |
$55.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.96
|
| Rate for Payer: PHCS Commercial |
$71.11
|
| Rate for Payer: United Healthcare All Payer |
$65.18
|
|
|
BENDEKA 1mg (from 100mg MDV)
|
Facility
|
OP
|
$134.83
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
25004023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$129.44 |
| Rate for Payer: Aetna Commercial |
$103.82
|
| Rate for Payer: Anthem Medicaid |
$46.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$105.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.92
|
| Rate for Payer: Cash Price |
$67.42
|
| Rate for Payer: Cash Price |
$67.42
|
| Rate for Payer: Cigna Commercial |
$111.91
|
| Rate for Payer: First Health Commercial |
$128.09
|
| Rate for Payer: Humana Commercial |
$114.61
|
| Rate for Payer: Humana KY Medicaid |
$46.37
|
| Rate for Payer: Humana Medicare Advantage |
$14.76
|
| Rate for Payer: Kentucky WC Medicaid |
$46.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.65
|
| Rate for Payer: Ohio Health Group HMO |
$101.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.80
|
| Rate for Payer: PHCS Commercial |
$129.44
|
| Rate for Payer: United Healthcare All Payer |
$118.65
|
|
|
BENDEKA 1mg (from 100mg MDV)
|
Facility
|
IP
|
$134.83
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
25004023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.53 |
| Max. Negotiated Rate |
$129.44 |
| Rate for Payer: Aetna Commercial |
$103.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$105.17
|
| Rate for Payer: Cash Price |
$67.42
|
| Rate for Payer: Cigna Commercial |
$111.91
|
| Rate for Payer: First Health Commercial |
$128.09
|
| Rate for Payer: Humana Commercial |
$114.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.65
|
| Rate for Payer: Ohio Health Group HMO |
$101.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.80
|
| Rate for Payer: PHCS Commercial |
$129.44
|
| Rate for Payer: United Healthcare All Payer |
$118.65
|
|
|
BENEMID(PROBENECID) 500MG/1TAB
|
Facility
|
OP
|
$4.83
|
|
|
Service Code
|
NDC 378015601
|
| Hospital Charge Code |
25000319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.01
|
| Rate for Payer: First Health Commercial |
$4.59
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.25
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Payer |
$4.25
|
|
|
BENEMID(PROBENECID) 500MG/1TAB
|
Facility
|
IP
|
$4.83
|
|
|
Service Code
|
NDC 378015601
|
| Hospital Charge Code |
25000319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.01
|
| Rate for Payer: First Health Commercial |
$4.59
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.25
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Payer |
$4.25
|
|
|
BENICAR 5MG TAB
|
Facility
|
OP
|
$4.31
|
|
|
Service Code
|
NDC 68462043630
|
| Hospital Charge Code |
25000321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
BENICAR 5MG TAB
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 68462043630
|
| Hospital Charge Code |
25000321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
BENICAR(OLMESARTAN)20MG TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 68462043730
|
| Hospital Charge Code |
25000322
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
