|
VAGINAL HYSTERECTOMY
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
76102219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAGINAL HYSTERECTOMY
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
76102219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$819.58 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$1,760.60
|
| Rate for Payer: Anthem Medicaid |
$819.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,724.35
|
| Rate for Payer: Healthspan PPO |
$1,704.71
|
| Rate for Payer: Humana Medicaid |
$819.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,502.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$835.97
|
| Rate for Payer: Molina Healthcare Passport |
$819.58
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$827.78
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
|
Facility
|
OP
|
$6,021.69
|
|
|
Service Code
|
CPT 58260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,301.21 |
| Max. Negotiated Rate |
$6,021.69 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,301.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,021.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,806.63
|
| Rate for Payer: Humana Medicare Advantage |
$4,301.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,161.45
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)
|
Facility
|
OP
|
$6,021.69
|
|
|
Service Code
|
CPT 58262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,301.21 |
| Max. Negotiated Rate |
$6,021.69 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,301.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,021.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,806.63
|
| Rate for Payer: Humana Medicare Advantage |
$4,301.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,161.45
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
|
Facility
|
OP
|
$9,148.36
|
|
|
Service Code
|
CPT 58290
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,534.54 |
| Max. Negotiated Rate |
$9,148.36 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,534.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,148.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,821.63
|
| Rate for Payer: Humana Medicare Advantage |
$6,534.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,841.45
|
|
|
VAGINAL HYSTERECTOMY(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
761P2219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$819.58 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$1,760.60
|
| Rate for Payer: Anthem Medicaid |
$819.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,724.35
|
| Rate for Payer: Healthspan PPO |
$1,704.71
|
| Rate for Payer: Humana Medicaid |
$819.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,502.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$835.97
|
| Rate for Payer: Molina Healthcare Passport |
$819.58
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$827.78
|
|
|
VAGISIL CREAM 30 GM
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 11509000367
|
| Hospital Charge Code |
25001639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.09
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.10
|
| Rate for Payer: First Health Commercial |
$0.11
|
| Rate for Payer: Humana Commercial |
$0.10
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
VAGISIL CREAM 30 GM
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 11509000367
|
| Hospital Charge Code |
25001639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.10
|
| Rate for Payer: First Health Commercial |
$0.11
|
| Rate for Payer: Humana Commercial |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
VAGISTAT 1 6.5% ONIT 4.6G
|
Facility
|
OP
|
$30.41
|
|
|
Service Code
|
NDC 63736044101
|
| Hospital Charge Code |
25001640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.19 |
| Rate for Payer: Aetna Commercial |
$23.42
|
| Rate for Payer: Anthem Medicaid |
$10.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.72
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cigna Commercial |
$25.24
|
| Rate for Payer: First Health Commercial |
$28.89
|
| Rate for Payer: Humana Commercial |
$25.85
|
| Rate for Payer: Humana KY Medicaid |
$10.46
|
| Rate for Payer: Kentucky WC Medicaid |
$10.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.76
|
| Rate for Payer: Ohio Health Group HMO |
$22.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.43
|
| Rate for Payer: PHCS Commercial |
$29.19
|
| Rate for Payer: United Healthcare All Payer |
$26.76
|
|
|
VAGISTAT 1 6.5% ONIT 4.6G
|
Facility
|
IP
|
$30.41
|
|
|
Service Code
|
NDC 63736044101
|
| Hospital Charge Code |
25001640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.19 |
| Rate for Payer: Aetna Commercial |
$23.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.72
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cigna Commercial |
$25.24
|
| Rate for Payer: First Health Commercial |
$28.89
|
| Rate for Payer: Humana Commercial |
$25.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.76
|
| Rate for Payer: Ohio Health Group HMO |
$22.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.43
|
| Rate for Payer: PHCS Commercial |
$29.19
|
| Rate for Payer: United Healthcare All Payer |
$26.76
|
|
|
VALCYTE 450 MG TABLET
|
Facility
|
OP
|
$27.25
|
|
|
Service Code
|
NDC 31722083260
|
| Hospital Charge Code |
25001641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$26.16 |
| Rate for Payer: Aetna Commercial |
$20.98
|
| Rate for Payer: Anthem Medicaid |
$9.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.26
|
| Rate for Payer: Cash Price |
$13.62
|
| Rate for Payer: Cigna Commercial |
$22.62
|
| Rate for Payer: First Health Commercial |
$25.89
|
| Rate for Payer: Humana Commercial |
$23.16
|
| Rate for Payer: Humana KY Medicaid |
$9.37
|
| Rate for Payer: Kentucky WC Medicaid |
$9.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.98
|
| Rate for Payer: Ohio Health Group HMO |
$20.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.45
|
| Rate for Payer: PHCS Commercial |
$26.16
|
| Rate for Payer: United Healthcare All Payer |
$23.98
|
|
|
VALCYTE 450 MG TABLET
|
Facility
|
IP
|
$27.25
|
|
|
Service Code
|
NDC 31722083260
|
| Hospital Charge Code |
25001641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$26.16 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.98
|
| Rate for Payer: Ohio Health Group HMO |
$20.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.45
|
| Rate for Payer: PHCS Commercial |
$26.16
|
| Rate for Payer: United Healthcare All Payer |
$23.98
|
| Rate for Payer: Aetna Commercial |
$20.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.26
|
| Rate for Payer: Cash Price |
$13.62
|
| Rate for Payer: Cigna Commercial |
$22.62
|
| Rate for Payer: First Health Commercial |
$25.89
|
| Rate for Payer: Humana Commercial |
$23.16
|
|
|
VALISONE 0.1% CREAM 45GRM
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
NDC 168004046
|
| Hospital Charge Code |
25001643
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| 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 |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
VALISONE 0.1% CREAM 45GRM
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
NDC 168004046
|
| Hospital Charge Code |
25001643
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| 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 |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
VALISONE(BETAMETH)0.1% CR 15GM
|
Facility
|
IP
|
$6.49
|
|
|
Service Code
|
NDC 168004015
|
| Hospital Charge Code |
25001644
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.06
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna Commercial |
$5.39
|
| Rate for Payer: First Health Commercial |
$6.17
|
| Rate for Payer: Humana Commercial |
$5.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.71
|
| Rate for Payer: Ohio Health Group HMO |
$4.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.01
|
| Rate for Payer: PHCS Commercial |
$6.23
|
| Rate for Payer: United Healthcare All Payer |
$5.71
|
|
|
VALISONE(BETAMETH)0.1% CR 15GM
|
Facility
|
OP
|
$6.49
|
|
|
Service Code
|
NDC 168004015
|
| Hospital Charge Code |
25001644
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Anthem Medicaid |
$2.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.06
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna Commercial |
$5.39
|
| Rate for Payer: First Health Commercial |
$6.17
|
| Rate for Payer: Humana Commercial |
$5.52
|
| Rate for Payer: Humana KY Medicaid |
$2.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.71
|
| Rate for Payer: Ohio Health Group HMO |
$4.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.01
|
| Rate for Payer: PHCS Commercial |
$6.23
|
| Rate for Payer: United Healthcare All Payer |
$5.71
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Facility
|
IP
|
$51.80
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
63600191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$49.73 |
| Rate for Payer: Aetna Commercial |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.40
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cigna Commercial |
$42.99
|
| Rate for Payer: First Health Commercial |
$49.21
|
| Rate for Payer: Humana Commercial |
$44.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.58
|
| Rate for Payer: Ohio Health Group HMO |
$38.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.06
|
| Rate for Payer: PHCS Commercial |
$49.73
|
| Rate for Payer: United Healthcare All Payer |
$45.58
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Facility
|
OP
|
$108.66
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
25002404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.13 |
| Max. Negotiated Rate |
$104.31 |
| Rate for Payer: Aetna Commercial |
$83.67
|
| Rate for Payer: Anthem Medicaid |
$37.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.75
|
| Rate for Payer: Cash Price |
$54.33
|
| Rate for Payer: Cigna Commercial |
$90.19
|
| Rate for Payer: First Health Commercial |
$103.23
|
| Rate for Payer: Humana Commercial |
$92.36
|
| Rate for Payer: Humana KY Medicaid |
$37.37
|
| Rate for Payer: Kentucky WC Medicaid |
$37.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.62
|
| Rate for Payer: Ohio Health Group HMO |
$81.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.68
|
| Rate for Payer: PHCS Commercial |
$104.31
|
| Rate for Payer: United Healthcare All Payer |
$95.62
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Facility
|
OP
|
$51.80
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
63600191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$49.73 |
| Rate for Payer: Aetna Commercial |
$39.89
|
| Rate for Payer: Anthem Medicaid |
$17.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.40
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cigna Commercial |
$42.99
|
| Rate for Payer: First Health Commercial |
$49.21
|
| Rate for Payer: Humana Commercial |
$44.03
|
| Rate for Payer: Humana KY Medicaid |
$17.81
|
| Rate for Payer: Kentucky WC Medicaid |
$18.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.58
|
| Rate for Payer: Ohio Health Group HMO |
$38.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.06
|
| Rate for Payer: PHCS Commercial |
$49.73
|
| Rate for Payer: United Healthcare All Payer |
$45.58
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Facility
|
IP
|
$108.66
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
25002404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.13 |
| Max. Negotiated Rate |
$104.31 |
| Rate for Payer: Aetna Commercial |
$83.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.75
|
| Rate for Payer: Cash Price |
$54.33
|
| Rate for Payer: Cigna Commercial |
$90.19
|
| Rate for Payer: First Health Commercial |
$103.23
|
| Rate for Payer: Humana Commercial |
$92.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.62
|
| Rate for Payer: Ohio Health Group HMO |
$81.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.68
|
| Rate for Payer: PHCS Commercial |
$104.31
|
| Rate for Payer: United Healthcare All Payer |
$95.62
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Professional
|
Both
|
$51.80
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
63600191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$51.80
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.04
|
| Rate for Payer: Multiplan PHCS |
$31.08
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$36.26
|
| Rate for Payer: UHCCP Medicaid |
$18.13
|
|
|
VALIUM 5 MG (10MG/2ML VL)(T
|
Facility
|
OP
|
$51.80
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
636T0191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$49.73 |
| Rate for Payer: Aetna Commercial |
$39.89
|
| Rate for Payer: Anthem Medicaid |
$17.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.40
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cigna Commercial |
$42.99
|
| Rate for Payer: First Health Commercial |
$49.21
|
| Rate for Payer: Humana Commercial |
$44.03
|
| Rate for Payer: Humana KY Medicaid |
$17.81
|
| Rate for Payer: Kentucky WC Medicaid |
$18.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.58
|
| Rate for Payer: Ohio Health Group HMO |
$38.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.06
|
| Rate for Payer: PHCS Commercial |
$49.73
|
| Rate for Payer: United Healthcare All Payer |
$45.58
|
|
|
VALIUM 5 MG (10MG/2ML VL)(T
|
Facility
|
IP
|
$51.80
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
636T0191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$49.73 |
| Rate for Payer: Aetna Commercial |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.40
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cigna Commercial |
$42.99
|
| Rate for Payer: First Health Commercial |
$49.21
|
| Rate for Payer: Humana Commercial |
$44.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.58
|
| Rate for Payer: Ohio Health Group HMO |
$38.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.06
|
| Rate for Payer: PHCS Commercial |
$49.73
|
| Rate for Payer: United Healthcare All Payer |
$45.58
|
|
|
VALIUM 5MG/5ML ORAL LIQUID
|
Facility
|
OP
|
$60.58
|
|
|
Service Code
|
NDC 54318863
|
| Hospital Charge Code |
25001645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$58.16 |
| Rate for Payer: Aetna Commercial |
$46.65
|
| Rate for Payer: Anthem Medicaid |
$20.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.25
|
| Rate for Payer: Cash Price |
$30.29
|
| Rate for Payer: Cigna Commercial |
$50.28
|
| Rate for Payer: First Health Commercial |
$57.55
|
| Rate for Payer: Humana Commercial |
$51.49
|
| Rate for Payer: Humana KY Medicaid |
$20.83
|
| Rate for Payer: Kentucky WC Medicaid |
$21.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.31
|
| Rate for Payer: Ohio Health Group HMO |
$45.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.78
|
| Rate for Payer: PHCS Commercial |
$58.16
|
| Rate for Payer: United Healthcare All Payer |
$53.31
|
|
|
VALIUM 5MG/5ML ORAL LIQUID
|
Facility
|
IP
|
$60.58
|
|
|
Service Code
|
NDC 54318863
|
| Hospital Charge Code |
25001645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$58.16 |
| Rate for Payer: Aetna Commercial |
$46.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.25
|
| Rate for Payer: Cash Price |
$30.29
|
| Rate for Payer: Cigna Commercial |
$50.28
|
| Rate for Payer: First Health Commercial |
$57.55
|
| Rate for Payer: Humana Commercial |
$51.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.31
|
| Rate for Payer: Ohio Health Group HMO |
$45.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.78
|
| Rate for Payer: PHCS Commercial |
$58.16
|
| Rate for Payer: United Healthcare All Payer |
$53.31
|
|
