|
THORACOTOMY(P
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS 32100
|
| Hospital Charge Code |
761P1174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$612.50 |
| Max. Negotiated Rate |
$1,609.01 |
| Rate for Payer: Aetna Commercial |
$1,609.01
|
| Rate for Payer: Ambetter Exchange |
$767.26
|
| Rate for Payer: Anthem Medicaid |
$648.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$767.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$767.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$920.71
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,523.27
|
| Rate for Payer: Healthspan PPO |
$1,256.27
|
| Rate for Payer: Humana Medicaid |
$648.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,323.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$767.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$660.96
|
| Rate for Payer: Molina Healthcare Passport |
$648.00
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$997.44
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$654.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$767.26
|
|
|
THORACOTOMY(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 32120
|
| Hospital Charge Code |
761P1176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$577.55 |
| Max. Negotiated Rate |
$1,427.30 |
| Rate for Payer: Aetna Commercial |
$1,427.30
|
| Rate for Payer: Ambetter Exchange |
$825.40
|
| Rate for Payer: Anthem Medicaid |
$577.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$825.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$825.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$990.48
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,344.52
|
| Rate for Payer: Healthspan PPO |
$1,114.40
|
| Rate for Payer: Humana Medicaid |
$577.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,205.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$825.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$825.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$589.10
|
| Rate for Payer: Molina Healthcare Passport |
$577.55
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,073.02
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$583.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$825.40
|
|
|
THORACOTOMY(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 32141
|
| Hospital Charge Code |
761P1178
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$777.66 |
| Max. Negotiated Rate |
$2,431.74 |
| Rate for Payer: Aetna Commercial |
$2,431.74
|
| Rate for Payer: Ambetter Exchange |
$1,434.19
|
| Rate for Payer: Anthem Medicaid |
$777.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,434.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,434.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,721.03
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,182.21
|
| Rate for Payer: Healthspan PPO |
$1,898.64
|
| Rate for Payer: Humana Medicaid |
$777.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,117.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,434.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,434.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$793.21
|
| Rate for Payer: Molina Healthcare Passport |
$777.66
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,864.45
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$785.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,434.19
|
|
|
THORACOTOMY(T
|
Facility
|
IP
|
$3,955.50
|
|
|
Service Code
|
HCPCS 32160
|
| Hospital Charge Code |
761T1180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,186.65 |
| Max. Negotiated Rate |
$3,797.28 |
| Rate for Payer: Aetna Commercial |
$3,045.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,085.29
|
| Rate for Payer: Cash Price |
$1,977.75
|
| Rate for Payer: Cigna Commercial |
$3,283.07
|
| Rate for Payer: First Health Commercial |
$3,757.72
|
| Rate for Payer: Humana Commercial |
$3,362.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,243.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,919.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,186.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,480.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,966.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,164.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,441.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,729.30
|
| Rate for Payer: PHCS Commercial |
$3,797.28
|
| Rate for Payer: United Healthcare All Payer |
$3,480.84
|
|
|
THORACOTOMY(T
|
Facility
|
OP
|
$3,955.50
|
|
|
Service Code
|
HCPCS 32160
|
| Hospital Charge Code |
761T1180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,186.65 |
| Max. Negotiated Rate |
$3,797.28 |
| Rate for Payer: Aetna Commercial |
$3,045.74
|
| Rate for Payer: Anthem Medicaid |
$1,360.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,085.29
|
| Rate for Payer: Cash Price |
$1,977.75
|
| Rate for Payer: Cigna Commercial |
$3,283.07
|
| Rate for Payer: First Health Commercial |
$3,757.72
|
| Rate for Payer: Humana Commercial |
$3,362.18
|
| Rate for Payer: Humana KY Medicaid |
$1,360.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,374.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,243.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,919.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,186.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,387.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,480.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,966.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,164.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,441.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,729.30
|
| Rate for Payer: PHCS Commercial |
$3,797.28
|
| Rate for Payer: United Healthcare All Payer |
$3,480.84
|
|
|
THORAZINE 100MG TABLET
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
25002702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$9.85 |
| Rate for Payer: Aetna Commercial |
$7.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna Commercial |
$8.52
|
| Rate for Payer: First Health Commercial |
$9.75
|
| Rate for Payer: Humana Commercial |
$8.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.03
|
| Rate for Payer: Ohio Health Group HMO |
$7.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.08
|
| Rate for Payer: PHCS Commercial |
$9.85
|
| Rate for Payer: United Healthcare All Payer |
$9.03
|
|
|
THORAZINE 100MG TABLET
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
25002702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$9.85 |
| Rate for Payer: Aetna Commercial |
$7.90
|
| Rate for Payer: Anthem Medicaid |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna Commercial |
$8.52
|
| Rate for Payer: First Health Commercial |
$9.75
|
| Rate for Payer: Humana Commercial |
$8.72
|
| Rate for Payer: Humana KY Medicaid |
$3.53
|
| Rate for Payer: Kentucky WC Medicaid |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.03
|
| Rate for Payer: Ohio Health Group HMO |
$7.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.08
|
| Rate for Payer: PHCS Commercial |
$9.85
|
| Rate for Payer: United Healthcare All Payer |
$9.03
|
|
|
THORAZINE(CHLORPROMA 25MG/1TAB
|
Facility
|
IP
|
$5.05
|
|
|
Service Code
|
NDC 69238105601
|
| Hospital Charge Code |
25001527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.19
|
| Rate for Payer: First Health Commercial |
$4.80
|
| Rate for Payer: Humana Commercial |
$4.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.85
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
THORAZINE(CHLORPROMA 25MG/1TAB
|
Facility
|
OP
|
$5.05
|
|
|
Service Code
|
NDC 69238105601
|
| Hospital Charge Code |
25001527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.19
|
| Rate for Payer: First Health Commercial |
$4.80
|
| Rate for Payer: Humana Commercial |
$4.29
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.85
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
THORAZINE(CHLORPROMAZ 50MG/2ML
|
Facility
|
IP
|
$189.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
25002384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.73 |
| 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 |
$179.65
|
| 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 |
$151.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.48
|
| Rate for Payer: PHCS Commercial |
$181.54
|
| Rate for Payer: United Healthcare All Payer |
$166.41
|
|
|
THORAZINE(CHLORPROMAZ 50MG/2ML
|
Facility
|
OP
|
$189.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
25002384
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.73 |
| 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 |
$179.65
|
| 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 |
$151.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.48
|
| 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 |
$298.60 |
| 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 |
$106.26
|
| 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 |
$106.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$115.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.39
|
| Rate for Payer: Molina Healthcare Passport |
$106.26
|
| 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 |
$107.32
|
|
|
THP-MORTIN (IPUPROFN)600MG TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 64380080806
|
| Hospital Charge Code |
25001533
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
THP-MORTIN (IPUPROFN)600MG TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 64380080806
|
| Hospital Charge Code |
25001533
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
THP-PHENERGAN (PROMET) 12.5MG
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
HCPCS J8597
|
| Hospital Charge Code |
25001536
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.38 |
| 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 |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
THP-PHENERGAN (PROMET) 12.5MG
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
HCPCS J8597
|
| Hospital Charge Code |
25001536
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.38 |
| 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 |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| 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 |
$1.38 |
| 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 |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| 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 |
$1.38 |
| 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 |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| 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 |
$1.35 |
| 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 |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| 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 |
$1.35 |
| 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 |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| 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 |
$278.87 |
| 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 |
$100.83
|
| 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 |
$100.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.85
|
| Rate for Payer: Molina Healthcare Passport |
$100.83
|
| 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 |
$101.84
|
|
|
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 |
$312.90 |
| 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 |
$95.21
|
| 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 |
$95.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.11
|
| Rate for Payer: Molina Healthcare Passport |
$95.21
|
| 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 |
$96.16
|
|
|
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 |
$134.10 |
| 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 |
$357.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$308.43
|
| Rate for Payer: PHCS Commercial |
$429.12
|
| Rate for Payer: United Healthcare All Payer |
$393.36
|
|
|
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 |
$134.10 |
| 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 |
$357.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$308.43
|
| 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 |
$171.50 |
| 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 |
$89.90
|
| 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 |
$89.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.70
|
| Rate for Payer: Molina Healthcare Passport |
$89.90
|
| 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 |
$90.80
|
|
