|
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 |
$13.41 |
| Max. Negotiated Rate |
$119.66 |
| Rate for Payer: Aetna Commercial |
$30.03
|
| Rate for Payer: Anthem Medicaid |
$13.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$115.38
|
| 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 |
$85.47
|
| 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 |
$102.56
|
| 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 |
$31.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.91
|
| Rate for Payer: PHCS Commercial |
$37.44
|
| Rate for Payer: United Healthcare All Payer |
$34.32
|
|
|
BEHAV QUAL VOICE RES ANALYSIS
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
HCPCS 92524
|
| Hospital Charge Code |
44000006
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$77.40 |
| Max. Negotiated Rate |
$247.68 |
| Rate for Payer: Aetna Commercial |
$198.66
|
| Rate for Payer: Anthem Medicaid |
$88.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$201.24
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$214.14
|
| Rate for Payer: First Health Commercial |
$245.10
|
| Rate for Payer: Humana Commercial |
$219.30
|
| Rate for Payer: Humana KY Medicaid |
$88.73
|
| Rate for Payer: Kentucky WC Medicaid |
$89.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$211.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$190.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$90.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$227.04
|
| Rate for Payer: Ohio Health Group HMO |
$193.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$224.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.02
|
| Rate for Payer: PHCS Commercial |
$247.68
|
| Rate for Payer: United Healthcare All Payer |
$227.04
|
|
|
BEHAV QUAL VOICE RES ANALYSIS
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
HCPCS 92524
|
| Hospital Charge Code |
44000006
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$77.40 |
| Max. Negotiated Rate |
$247.68 |
| Rate for Payer: Aetna Commercial |
$198.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$201.24
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$214.14
|
| Rate for Payer: First Health Commercial |
$245.10
|
| Rate for Payer: Humana Commercial |
$219.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$211.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$190.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$227.04
|
| Rate for Payer: Ohio Health Group HMO |
$193.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$224.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.02
|
| Rate for Payer: PHCS Commercial |
$247.68
|
| Rate for Payer: United Healthcare All Payer |
$227.04
|
|
|
BELATACEPT 1mg (250mg SDV)
|
Facility
|
OP
|
$5,285.85
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
25004471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| 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 |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,122.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.25
|
| 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 |
$3.89
|
| 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 |
$4.67
|
| 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 |
$4,228.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,598.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,647.24
|
| 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 |
$1,585.76 |
| 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 |
$4,228.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,598.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,647.24
|
| 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
|
$4.38
|
|
|
Service Code
|
NDC 121048900
|
| Hospital Charge Code |
25000315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| 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 |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
BENADRYL 12.5MG/5ML ELIXIR
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 121048900
|
| Hospital Charge Code |
25000315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| 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 |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
BENADRYL(DIPHENHYDRA 25MG/1TAB
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
25000316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| 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 |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.16
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
BENADRYL(DIPHENHYDRA 25MG/1TAB
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
25000316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| 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 |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.16
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
BENADRYL(DIPHENHYDRA 50MG/1CAP
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
25002705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| 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 |
$1.27
|
| 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 |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
BENADRYL(DIPHENHYDRA 50MG/1CAP
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
25002705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| 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 |
$3.31
|
| 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 |
$1.27
|
| 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 |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
IP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
636T0031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| 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 |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
IP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
25002034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| 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 |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
OP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
25002034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| 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 |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
OP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
636T0031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| 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 |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
OP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
63600031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| 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 |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Facility
|
IP
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
63600031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| 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 |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.08
|
| Rate for Payer: United Healthcare All Payer |
$67.91
|
|
|
BENADRYL (DIPHENHYDRA 50MG/1ML
|
Professional
|
Both
|
$77.17
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
63600031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$46.30 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Ambetter Exchange |
$0.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.90
|
| Rate for Payer: Multiplan PHCS |
$46.30
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.17
|
| Rate for Payer: UHCCP Medicaid |
$27.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.90
|
|
|
BENDEKA 1mg (from 100mg MDV)
|
Facility
|
IP
|
$134.83
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
25004023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.45 |
| 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 |
$107.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.03
|
| Rate for Payer: PHCS Commercial |
$129.44
|
| Rate for Payer: United Healthcare All Payer |
$118.65
|
|
|
BENDEKA 1mg (from 100mg MDV)
|
Facility
|
OP
|
$134.83
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
25004023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| 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 |
$13.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$105.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.71
|
| 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 |
$13.12
|
| 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 |
$15.74
|
| 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 |
$107.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.03
|
| 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 |
$1.45 |
| 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 |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| 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 |
$1.45 |
| 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 |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| 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 |
$1.29 |
| 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 |
$3.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| 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 |
$1.29 |
| 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 |
$3.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| 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 |
$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
|
|
