|
THORAZINE(CHLORPROMAZ 50MG/2ML
|
Facility
|
OP
|
$189.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
25002384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.58 |
| Max. Negotiated Rate |
$181.54 |
| Rate for Payer: Aetna Commercial |
$145.61
|
| Rate for Payer: Anthem Medicaid |
$65.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.50
|
| Rate for Payer: Cash Price |
$94.55
|
| Rate for Payer: Cigna Commercial |
$156.95
|
| Rate for Payer: First Health Commercial |
$179.64
|
| Rate for Payer: Humana Commercial |
$160.74
|
| Rate for Payer: Humana KY Medicaid |
$65.03
|
| Rate for Payer: Kentucky WC Medicaid |
$65.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.41
|
| Rate for Payer: Ohio Health Group HMO |
$141.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.62
|
| Rate for Payer: PHCS Commercial |
$181.54
|
| Rate for Payer: United Healthcare All Payer |
$166.41
|
|
|
THORAZINE(CHLORPROMAZ 50MG/2ML
|
Facility
|
IP
|
$189.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
25002384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.58 |
| Max. Negotiated Rate |
$181.54 |
| Rate for Payer: Aetna Commercial |
$145.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.50
|
| Rate for Payer: Cash Price |
$94.55
|
| Rate for Payer: Cigna Commercial |
$156.95
|
| Rate for Payer: First Health Commercial |
$179.64
|
| Rate for Payer: Humana Commercial |
$160.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.41
|
| Rate for Payer: Ohio Health Group HMO |
$141.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.62
|
| Rate for Payer: PHCS Commercial |
$181.54
|
| Rate for Payer: United Healthcare All Payer |
$166.41
|
|
|
TH PER PM REEVAL EST PT 65+ YR
|
Professional
|
Both
|
$426.57
|
|
|
Service Code
|
HCPCS 99397
|
| Hospital Charge Code |
51000311
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$426.57 |
| Rate for Payer: Aetna Commercial |
$135.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$81.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$426.57
|
| Rate for Payer: Cash Price |
$213.28
|
| Rate for Payer: Cash Price |
$213.28
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: Healthspan PPO |
$137.26
|
| Rate for Payer: Humana Medicaid |
$81.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$115.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.81
|
| Rate for Payer: Molina Healthcare Passport |
$81.19
|
| Rate for Payer: Multiplan PHCS |
$255.94
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$298.60
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: United Healthcare Non-Options |
$93.05
|
| Rate for Payer: United Healthcare Options |
$76.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.00
|
|
|
THP-MORTIN (IPUPROFN)600MG TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 64380080806
|
| Hospital Charge Code |
25001533
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
THP-MORTIN (IPUPROFN)600MG TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 64380080806
|
| Hospital Charge Code |
25001533
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
THP-PHENERGAN (PROMET) 12.5MG
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
HCPCS J8597
|
| Hospital Charge Code |
25001536
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| 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 |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
THP-PHENERGAN (PROMET) 12.5MG
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
HCPCS J8597
|
| Hospital Charge Code |
25001536
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| 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 |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
THP-PHENERGAN (PROMET) 25MG #2
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 51672529701
|
| Hospital Charge Code |
25001537
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| 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 |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
THP-PHENERGAN (PROMET) 25MG #2
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 51672529701
|
| Hospital Charge Code |
25001537
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| 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 |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
THP-PHENERGAN(PROMETH)25MG TAB
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
25001538
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
THP-PHENERGAN(PROMETH)25MG TAB
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
25001538
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
TH PREVENT VISIT - 40-64 YR
|
Professional
|
Both
|
$398.38
|
|
|
Service Code
|
HCPCS 99396
|
| Hospital Charge Code |
51000296
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$398.38 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.45
|
| Rate for Payer: Anthem Medicaid |
$76.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$398.38
|
| Rate for Payer: Cash Price |
$199.19
|
| Rate for Payer: Cash Price |
$199.19
|
| Rate for Payer: Cigna Commercial |
$149.95
|
| Rate for Payer: Healthspan PPO |
$122.46
|
| Rate for Payer: Humana Medicaid |
$76.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.07
|
| Rate for Payer: Molina Healthcare Passport |
$76.54
|
| Rate for Payer: Multiplan PHCS |
$239.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$278.87
|
| Rate for Payer: UHCCP Medicaid |
$50.87
|
| Rate for Payer: United Healthcare Non-Options |
$83.32
|
| Rate for Payer: United Healthcare Options |
$68.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$77.31
|
|
|
TH PREVENT VISIT-NEW AGE 18-39
|
Professional
|
Both
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
51000297
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.97 |
| Max. Negotiated Rate |
$447.00 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.97
|
| Rate for Payer: Anthem Medicaid |
$77.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$447.00
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$77.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.15
|
| Rate for Payer: Molina Healthcare Passport |
$77.60
|
| Rate for Payer: Multiplan PHCS |
$268.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.90
|
| Rate for Payer: UHCCP Medicaid |
$51.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.38
|
|
|
TH PREVENT VISIT-NEW AGE 18-39
|
Facility
|
IP
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
51000297
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$58.11 |
| Max. Negotiated Rate |
$429.12 |
| Rate for Payer: Aetna Commercial |
$344.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$348.66
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$371.01
|
| Rate for Payer: First Health Commercial |
$424.65
|
| Rate for Payer: Humana Commercial |
$379.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$366.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$329.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$134.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$393.36
|
| Rate for Payer: Ohio Health Group HMO |
$335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.57
|
| Rate for Payer: PHCS Commercial |
$429.12
|
| Rate for Payer: United Healthcare All Payer |
$393.36
|
|
|
TH PREVENT VISIT-NEW AGE 18-39
|
Facility
|
OP
|
$447.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
51000297
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$58.11 |
| Max. Negotiated Rate |
$429.12 |
| Rate for Payer: Aetna Commercial |
$344.19
|
| Rate for Payer: Anthem Medicaid |
$153.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$348.66
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$371.01
|
| Rate for Payer: First Health Commercial |
$424.65
|
| Rate for Payer: Humana Commercial |
$379.95
|
| Rate for Payer: Humana KY Medicaid |
$153.72
|
| Rate for Payer: Kentucky WC Medicaid |
$155.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$366.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$329.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$134.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$156.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$393.36
|
| Rate for Payer: Ohio Health Group HMO |
$335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.57
|
| Rate for Payer: PHCS Commercial |
$429.12
|
| Rate for Payer: United Healthcare All Payer |
$393.36
|
|
|
TH PREVENT VISIT-NEW AGE5-11
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
51000310
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.31
|
| Rate for Payer: Anthem Medicaid |
$68.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.00
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$150.41
|
| Rate for Payer: Healthspan PPO |
$115.91
|
| Rate for Payer: Humana Medicaid |
$68.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.63
|
| Rate for Payer: Molina Healthcare Passport |
$68.26
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$44.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.94
|
|
|
TH PREVENT VISIT - UNDER 1
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000312
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna Commercial |
$80.47
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.78
|
| Rate for Payer: Anthem Medicaid |
$55.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.00
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$110.62
|
| Rate for Payer: Healthspan PPO |
$91.25
|
| Rate for Payer: Humana Medicaid |
$55.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.27
|
| Rate for Payer: Molina Healthcare Passport |
$55.17
|
| Rate for Payer: Multiplan PHCS |
$123.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.50
|
| Rate for Payer: UHCCP Medicaid |
$36.52
|
| Rate for Payer: United Healthcare Non-Options |
$55.42
|
| Rate for Payer: United Healthcare Options |
$45.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.72
|
|
|
TH PREVENT VIS NEW 65 & OLDER
|
Professional
|
Both
|
$509.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
51000316
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.93 |
| Max. Negotiated Rate |
$509.00 |
| Rate for Payer: Aetna Commercial |
$162.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.93
|
| Rate for Payer: Anthem Medicaid |
$101.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$509.00
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$208.03
|
| Rate for Payer: Healthspan PPO |
$162.38
|
| Rate for Payer: Humana Medicaid |
$101.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.43
|
| Rate for Payer: Molina Healthcare Passport |
$101.40
|
| Rate for Payer: Multiplan PHCS |
$305.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$356.30
|
| Rate for Payer: UHCCP Medicaid |
$70.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.41
|
|
|
TH PREVENT VIS NEW PT AGE 1-4
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
51000318
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.74 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.74
|
| Rate for Payer: Anthem Medicaid |
$64.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$152.62
|
| Rate for Payer: Healthspan PPO |
$116.32
|
| Rate for Payer: Humana Medicaid |
$64.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.67
|
| Rate for Payer: Molina Healthcare Passport |
$64.38
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$44.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.02
|
|
|
TH PREV VISIT NEW AGE 12-17
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000319
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$80.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$80.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.03
|
| Rate for Payer: Molina Healthcare Passport |
$80.42
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.22
|
|
|
TH PREV VISIT NEW AGE 40-64
|
Professional
|
Both
|
$269.50
|
|
|
Service Code
|
HCPCS 99386
|
| Hospital Charge Code |
51000295
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.29 |
| Max. Negotiated Rate |
$269.50 |
| Rate for Payer: Aetna Commercial |
$148.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$62.29
|
| Rate for Payer: Anthem Medicaid |
$93.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$269.50
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cigna Commercial |
$191.42
|
| Rate for Payer: Healthspan PPO |
$147.58
|
| Rate for Payer: Humana Medicaid |
$93.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$125.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.87
|
| Rate for Payer: Molina Healthcare Passport |
$93.99
|
| Rate for Payer: Multiplan PHCS |
$161.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.65
|
| Rate for Payer: UHCCP Medicaid |
$65.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.93
|
|
|
TH PSYCH DIAG EVAL W/MED SRVCS
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 90792
|
| Hospital Charge Code |
51000186
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.90 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$213.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$87.90
|
| Rate for Payer: Anthem Medicaid |
$102.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$184.98
|
| Rate for Payer: Healthspan PPO |
$110.67
|
| Rate for Payer: Humana Medicaid |
$102.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$177.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.54
|
| Rate for Payer: Molina Healthcare Passport |
$102.49
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$92.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.51
|
|
|
THP-VISTARIL 50 MG CAPS #2
|
Facility
|
OP
|
$5.09
|
|
|
Service Code
|
NDC 185067601
|
| Hospital Charge Code |
25001542
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Humana KY Medicaid |
$1.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
THP-VISTARIL 50 MG CAPS #2
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 185067601
|
| Hospital Charge Code |
25001542
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
THP-ZOFRAN-ODT 4MG TABLET
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 57237007530
|
| Hospital Charge Code |
25001543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| 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 |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
