|
VERSA-DIAL 58*24*64MM HMRL HED
|
Facility
|
IP
|
$8,753.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,137.91 |
| Max. Negotiated Rate |
$8,403.02 |
| Rate for Payer: Aetna Commercial |
$6,739.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,827.46
|
| Rate for Payer: Cash Price |
$4,376.58
|
| Rate for Payer: Cigna Commercial |
$7,265.11
|
| Rate for Payer: First Health Commercial |
$8,315.49
|
| Rate for Payer: Humana Commercial |
$7,440.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,177.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,459.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,625.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,702.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,564.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,750.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,137.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.48
|
| Rate for Payer: PHCS Commercial |
$8,403.02
|
| Rate for Payer: United Healthcare All Payer |
$7,702.77
|
|
|
VERSA-DIAL 58*27*61MM HMRL HED
|
Facility
|
IP
|
$8,753.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,137.91 |
| Max. Negotiated Rate |
$8,403.02 |
| Rate for Payer: Aetna Commercial |
$6,739.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,827.46
|
| Rate for Payer: Cash Price |
$4,376.58
|
| Rate for Payer: Cigna Commercial |
$7,265.11
|
| Rate for Payer: First Health Commercial |
$8,315.49
|
| Rate for Payer: Humana Commercial |
$7,440.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,177.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,459.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,625.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,702.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,564.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,750.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,137.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.48
|
| Rate for Payer: PHCS Commercial |
$8,403.02
|
| Rate for Payer: United Healthcare All Payer |
$7,702.77
|
|
|
VERSA-DIAL 58*27*61MM HMRL HED
|
Facility
|
OP
|
$8,753.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,137.91 |
| Max. Negotiated Rate |
$8,403.02 |
| Rate for Payer: Aetna Commercial |
$6,739.93
|
| Rate for Payer: Anthem Medicaid |
$3,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,827.46
|
| Rate for Payer: Cash Price |
$4,376.58
|
| Rate for Payer: Cigna Commercial |
$7,265.11
|
| Rate for Payer: First Health Commercial |
$8,315.49
|
| Rate for Payer: Humana Commercial |
$7,440.18
|
| Rate for Payer: Humana KY Medicaid |
$3,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3,040.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,177.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,459.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,625.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,070.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,702.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,564.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,750.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,137.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.48
|
| Rate for Payer: PHCS Commercial |
$8,403.02
|
| Rate for Payer: United Healthcare All Payer |
$7,702.77
|
|
|
VERSA-DIAL COMP TI STD TAPER
|
Facility
|
IP
|
$1,959.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$254.67 |
| Max. Negotiated Rate |
$1,880.64 |
| Rate for Payer: Aetna Commercial |
$1,508.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,528.02
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cigna Commercial |
$1,625.97
|
| Rate for Payer: First Health Commercial |
$1,861.05
|
| Rate for Payer: Humana Commercial |
$1,665.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,606.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,445.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$587.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,723.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,469.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$391.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$254.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$607.29
|
| Rate for Payer: PHCS Commercial |
$1,880.64
|
| Rate for Payer: United Healthcare All Payer |
$1,723.92
|
|
|
VERSA-DIAL COMP TI STD TAPER
|
Facility
|
OP
|
$1,959.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$254.67 |
| Max. Negotiated Rate |
$1,880.64 |
| Rate for Payer: Aetna Commercial |
$1,508.43
|
| Rate for Payer: Anthem Medicaid |
$673.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,528.02
|
| Rate for Payer: Cash Price |
$979.50
|
| Rate for Payer: Cigna Commercial |
$1,625.97
|
| Rate for Payer: First Health Commercial |
$1,861.05
|
| Rate for Payer: Humana Commercial |
$1,665.15
|
| Rate for Payer: Humana KY Medicaid |
$673.70
|
| Rate for Payer: Kentucky WC Medicaid |
$680.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,606.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,445.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$587.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$687.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,723.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,469.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$391.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$254.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$607.29
|
| Rate for Payer: PHCS Commercial |
$1,880.64
|
| Rate for Payer: United Healthcare All Payer |
$1,723.92
|
|
|
VERSALOK ANCHOR W/ORTHOCORD
|
Facility
|
IP
|
$3,432.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$446.16 |
| Max. Negotiated Rate |
$3,294.72 |
| Rate for Payer: Humana Commercial |
$2,917.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,814.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,532.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,029.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,020.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,574.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$686.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$446.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.92
|
| Rate for Payer: PHCS Commercial |
$3,294.72
|
| Rate for Payer: United Healthcare All Payer |
$3,020.16
|
| Rate for Payer: Aetna Commercial |
$2,642.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,676.96
|
| Rate for Payer: Cash Price |
$1,716.00
|
| Rate for Payer: Cigna Commercial |
$2,848.56
|
| Rate for Payer: First Health Commercial |
$3,260.40
|
|
|
VERSALOK ANCHOR W/ORTHOCORD
|
Facility
|
OP
|
$3,432.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$446.16 |
| Max. Negotiated Rate |
$3,294.72 |
| Rate for Payer: Aetna Commercial |
$2,642.64
|
| Rate for Payer: Anthem Medicaid |
$1,180.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,676.96
|
| Rate for Payer: Cash Price |
$1,716.00
|
| Rate for Payer: Cigna Commercial |
$2,848.56
|
| Rate for Payer: First Health Commercial |
$3,260.40
|
| Rate for Payer: Humana Commercial |
$2,917.20
|
| Rate for Payer: Humana KY Medicaid |
$1,180.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,192.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,814.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,532.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,029.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,203.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,020.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,574.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$686.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$446.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.92
|
| Rate for Payer: PHCS Commercial |
$3,294.72
|
| Rate for Payer: United Healthcare All Payer |
$3,020.16
|
|
|
VERSED 1mg (100mg/100mL Drip)
|
Facility
|
IP
|
$68.38
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25004464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$65.64 |
| Rate for Payer: Aetna Commercial |
$52.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.34
|
| Rate for Payer: Cash Price |
$34.19
|
| Rate for Payer: Cigna Commercial |
$56.76
|
| Rate for Payer: First Health Commercial |
$64.96
|
| Rate for Payer: Humana Commercial |
$58.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.17
|
| Rate for Payer: Ohio Health Group HMO |
$51.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.20
|
| Rate for Payer: PHCS Commercial |
$65.64
|
| Rate for Payer: United Healthcare All Payer |
$60.17
|
|
|
VERSED 1mg (100mg/100mL Drip)
|
Facility
|
OP
|
$68.38
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25004464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$65.64 |
| Rate for Payer: Aetna Commercial |
$52.65
|
| Rate for Payer: Anthem Medicaid |
$23.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.34
|
| Rate for Payer: Cash Price |
$34.19
|
| Rate for Payer: Cigna Commercial |
$56.76
|
| Rate for Payer: First Health Commercial |
$64.96
|
| Rate for Payer: Humana Commercial |
$58.12
|
| Rate for Payer: Humana KY Medicaid |
$23.52
|
| Rate for Payer: Kentucky WC Medicaid |
$23.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.17
|
| Rate for Payer: Ohio Health Group HMO |
$51.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.20
|
| Rate for Payer: PHCS Commercial |
$65.64
|
| Rate for Payer: United Healthcare All Payer |
$60.17
|
|
|
VERSED 1 MG[10MG/10ML VIAL]
|
Facility
|
OP
|
$77.27
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$74.18 |
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Anthem Medicaid |
$26.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.27
|
| Rate for Payer: Cash Price |
$38.63
|
| Rate for Payer: Cigna Commercial |
$64.13
|
| Rate for Payer: First Health Commercial |
$73.41
|
| Rate for Payer: Humana Commercial |
$65.68
|
| Rate for Payer: Humana KY Medicaid |
$26.57
|
| Rate for Payer: Kentucky WC Medicaid |
$26.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.00
|
| Rate for Payer: Ohio Health Group HMO |
$57.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.95
|
| Rate for Payer: PHCS Commercial |
$74.18
|
| Rate for Payer: United Healthcare All Payer |
$68.00
|
|
|
VERSED 1 MG[10MG/10ML VIAL]
|
Facility
|
IP
|
$77.27
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$74.18 |
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.27
|
| Rate for Payer: Cash Price |
$38.63
|
| Rate for Payer: Cigna Commercial |
$64.13
|
| Rate for Payer: First Health Commercial |
$73.41
|
| Rate for Payer: Humana Commercial |
$65.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.00
|
| Rate for Payer: Ohio Health Group HMO |
$57.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.95
|
| Rate for Payer: PHCS Commercial |
$74.18
|
| Rate for Payer: United Healthcare All Payer |
$68.00
|
|
|
VERSED 1MG (2mg PF VIAL)
|
Facility
|
IP
|
$73.97
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002238
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.01 |
| Rate for Payer: Aetna Commercial |
$56.96
|
| Rate for Payer: Aetna Commercial |
$58.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.26
|
| Rate for Payer: Cash Price |
$36.98
|
| Rate for Payer: Cash Price |
$37.98
|
| Rate for Payer: Cigna Commercial |
$61.40
|
| Rate for Payer: Cigna Commercial |
$63.06
|
| Rate for Payer: First Health Commercial |
$72.17
|
| Rate for Payer: First Health Commercial |
$70.27
|
| Rate for Payer: Humana Commercial |
$64.57
|
| Rate for Payer: Humana Commercial |
$62.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.85
|
| Rate for Payer: Ohio Health Group HMO |
$55.48
|
| Rate for Payer: Ohio Health Group HMO |
$56.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.93
|
| Rate for Payer: PHCS Commercial |
$71.01
|
| Rate for Payer: PHCS Commercial |
$72.93
|
| Rate for Payer: United Healthcare All Payer |
$65.09
|
| Rate for Payer: United Healthcare All Payer |
$66.85
|
|
|
VERSED 1MG (2mg PF VIAL)
|
Facility
|
OP
|
$73.97
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002238
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.01 |
| Rate for Payer: Aetna Commercial |
$56.96
|
| Rate for Payer: Aetna Commercial |
$58.50
|
| Rate for Payer: Anthem Medicaid |
$25.44
|
| Rate for Payer: Anthem Medicaid |
$26.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.26
|
| Rate for Payer: Cash Price |
$36.98
|
| Rate for Payer: Cash Price |
$37.98
|
| Rate for Payer: Cigna Commercial |
$63.06
|
| Rate for Payer: Cigna Commercial |
$61.40
|
| Rate for Payer: First Health Commercial |
$72.17
|
| Rate for Payer: First Health Commercial |
$70.27
|
| Rate for Payer: Humana Commercial |
$62.87
|
| Rate for Payer: Humana Commercial |
$64.57
|
| Rate for Payer: Humana KY Medicaid |
$25.44
|
| Rate for Payer: Humana KY Medicaid |
$26.13
|
| Rate for Payer: Kentucky WC Medicaid |
$26.39
|
| Rate for Payer: Kentucky WC Medicaid |
$25.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.85
|
| Rate for Payer: Ohio Health Group HMO |
$55.48
|
| Rate for Payer: Ohio Health Group HMO |
$56.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.55
|
| Rate for Payer: PHCS Commercial |
$72.93
|
| Rate for Payer: PHCS Commercial |
$71.01
|
| Rate for Payer: United Healthcare All Payer |
$66.85
|
| Rate for Payer: United Healthcare All Payer |
$65.09
|
|
|
VERSED 1 MG [50MG/10ML]
|
Facility
|
OP
|
$82.52
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002234
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$79.22 |
| Rate for Payer: Aetna Commercial |
$63.54
|
| Rate for Payer: Anthem Medicaid |
$28.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64.37
|
| Rate for Payer: Cash Price |
$41.26
|
| Rate for Payer: Cigna Commercial |
$68.49
|
| Rate for Payer: First Health Commercial |
$78.39
|
| Rate for Payer: Humana Commercial |
$70.14
|
| Rate for Payer: Humana KY Medicaid |
$28.38
|
| Rate for Payer: Kentucky WC Medicaid |
$28.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.62
|
| Rate for Payer: Ohio Health Group HMO |
$61.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.58
|
| Rate for Payer: PHCS Commercial |
$79.22
|
| Rate for Payer: United Healthcare All Payer |
$72.62
|
|
|
VERSED 1 MG [50MG/10ML]
|
Facility
|
IP
|
$82.52
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002234
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$79.22 |
| Rate for Payer: Aetna Commercial |
$63.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64.37
|
| Rate for Payer: Cash Price |
$41.26
|
| Rate for Payer: Cigna Commercial |
$68.49
|
| Rate for Payer: First Health Commercial |
$78.39
|
| Rate for Payer: Humana Commercial |
$70.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.62
|
| Rate for Payer: Ohio Health Group HMO |
$61.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.58
|
| Rate for Payer: PHCS Commercial |
$79.22
|
| Rate for Payer: United Healthcare All Payer |
$72.62
|
|
|
VERSED 1MG (5MG/ML VL)
|
Facility
|
IP
|
$77.84
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$59.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.72
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Cigna Commercial |
$64.61
|
| Rate for Payer: First Health Commercial |
$73.95
|
| Rate for Payer: Humana Commercial |
$66.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.50
|
| Rate for Payer: Ohio Health Group HMO |
$58.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.13
|
| Rate for Payer: PHCS Commercial |
$74.73
|
| Rate for Payer: United Healthcare All Payer |
$68.50
|
|
|
VERSED 1MG (5MG/ML VL)
|
Facility
|
OP
|
$77.84
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$59.94
|
| Rate for Payer: Anthem Medicaid |
$26.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.72
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Cigna Commercial |
$64.61
|
| Rate for Payer: First Health Commercial |
$73.95
|
| Rate for Payer: Humana Commercial |
$66.16
|
| Rate for Payer: Humana KY Medicaid |
$26.77
|
| Rate for Payer: Kentucky WC Medicaid |
$27.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.50
|
| Rate for Payer: Ohio Health Group HMO |
$58.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.13
|
| Rate for Payer: PHCS Commercial |
$74.73
|
| Rate for Payer: United Healthcare All Payer |
$68.50
|
|
|
VERSED (MIDAZOLAM) 5MG/2.5ML
|
Facility
|
OP
|
$10.75
|
|
|
Service Code
|
NDC 54356699
|
| Hospital Charge Code |
25003569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.32 |
| Rate for Payer: Aetna Commercial |
$8.28
|
| Rate for Payer: Anthem Medicaid |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna Commercial |
$8.92
|
| Rate for Payer: First Health Commercial |
$10.21
|
| Rate for Payer: Humana Commercial |
$9.14
|
| Rate for Payer: Humana KY Medicaid |
$3.70
|
| Rate for Payer: Kentucky WC Medicaid |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.46
|
| Rate for Payer: Ohio Health Group HMO |
$8.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Payer |
$9.46
|
|
|
VERSED (MIDAZOLAM) 5MG/2.5ML
|
Facility
|
IP
|
$10.75
|
|
|
Service Code
|
NDC 54356699
|
| Hospital Charge Code |
25003569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.32 |
| Rate for Payer: Aetna Commercial |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna Commercial |
$8.92
|
| Rate for Payer: First Health Commercial |
$10.21
|
| Rate for Payer: Humana Commercial |
$9.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.46
|
| Rate for Payer: Ohio Health Group HMO |
$8.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Payer |
$9.46
|
|
|
VERTEBROPLASTY ADDL INJECT
|
Facility
|
IP
|
$7,190.26
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
76100423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$934.73 |
| Max. Negotiated Rate |
$6,902.65 |
| Rate for Payer: Aetna Commercial |
$5,536.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,608.40
|
| Rate for Payer: Cash Price |
$3,595.13
|
| Rate for Payer: Cigna Commercial |
$5,967.92
|
| Rate for Payer: First Health Commercial |
$6,830.75
|
| Rate for Payer: Humana Commercial |
$6,111.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,896.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,306.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,157.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,327.43
|
| Rate for Payer: Ohio Health Group HMO |
$5,392.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,438.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$934.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,228.98
|
| Rate for Payer: PHCS Commercial |
$6,902.65
|
| Rate for Payer: United Healthcare All Payer |
$6,327.43
|
|
|
VERTEBROPLASTY ADDL INJECT
|
Facility
|
OP
|
$7,190.26
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
76100423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$934.73 |
| Max. Negotiated Rate |
$6,902.65 |
| Rate for Payer: Aetna Commercial |
$5,536.50
|
| Rate for Payer: Anthem Medicaid |
$2,472.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,608.40
|
| Rate for Payer: Cash Price |
$3,595.13
|
| Rate for Payer: Cigna Commercial |
$5,967.92
|
| Rate for Payer: First Health Commercial |
$6,830.75
|
| Rate for Payer: Humana Commercial |
$6,111.72
|
| Rate for Payer: Humana KY Medicaid |
$2,472.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,497.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,896.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,306.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,157.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,522.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,327.43
|
| Rate for Payer: Ohio Health Group HMO |
$5,392.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,438.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$934.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,228.98
|
| Rate for Payer: PHCS Commercial |
$6,902.65
|
| Rate for Payer: United Healthcare All Payer |
$6,327.43
|
|
|
VERTEBROPLASTY ADDL INJECT
|
Professional
|
Both
|
$7,190.26
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
76100423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$7,190.26 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.25
|
| Rate for Payer: Anthem Medicaid |
$172.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,190.26
|
| Rate for Payer: Cash Price |
$3,595.13
|
| Rate for Payer: Cash Price |
$3,595.13
|
| Rate for Payer: Cigna Commercial |
$401.45
|
| Rate for Payer: Humana Medicaid |
$172.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.55
|
| Rate for Payer: Molina Healthcare Passport |
$172.11
|
| Rate for Payer: Multiplan PHCS |
$4,314.16
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,033.18
|
| Rate for Payer: UHCCP Medicaid |
$170.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$173.83
|
|
|
VERTEBROPLASTY ADDL INJECT(P
|
Professional
|
Both
|
$2,325.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
761P0423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$2,325.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.25
|
| Rate for Payer: Anthem Medicaid |
$172.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,325.00
|
| Rate for Payer: Cash Price |
$1,162.50
|
| Rate for Payer: Cash Price |
$1,162.50
|
| Rate for Payer: Cigna Commercial |
$401.45
|
| Rate for Payer: Humana Medicaid |
$172.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$175.55
|
| Rate for Payer: Molina Healthcare Passport |
$172.11
|
| Rate for Payer: Multiplan PHCS |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,627.50
|
| Rate for Payer: UHCCP Medicaid |
$170.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$173.83
|
|
|
VERTEBROPLASTY ADDL INJECT(T
|
Facility
|
OP
|
$4,865.26
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
761T0423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$632.48 |
| Max. Negotiated Rate |
$4,670.65 |
| Rate for Payer: Aetna Commercial |
$3,746.25
|
| Rate for Payer: Anthem Medicaid |
$1,673.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,794.90
|
| Rate for Payer: Cash Price |
$2,432.63
|
| Rate for Payer: Cigna Commercial |
$4,038.17
|
| Rate for Payer: First Health Commercial |
$4,622.00
|
| Rate for Payer: Humana Commercial |
$4,135.47
|
| Rate for Payer: Humana KY Medicaid |
$1,673.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,690.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,989.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,590.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,459.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,706.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,281.43
|
| Rate for Payer: Ohio Health Group HMO |
$3,648.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$973.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$632.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,508.23
|
| Rate for Payer: PHCS Commercial |
$4,670.65
|
| Rate for Payer: United Healthcare All Payer |
$4,281.43
|
|
|
VERTEBROPLASTY ADDL INJECT(T
|
Facility
|
IP
|
$4,865.26
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
761T0423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$632.48 |
| Max. Negotiated Rate |
$4,670.65 |
| Rate for Payer: Aetna Commercial |
$3,746.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,794.90
|
| Rate for Payer: Cash Price |
$2,432.63
|
| Rate for Payer: Cigna Commercial |
$4,038.17
|
| Rate for Payer: First Health Commercial |
$4,622.00
|
| Rate for Payer: Humana Commercial |
$4,135.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,989.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,590.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,459.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,281.43
|
| Rate for Payer: Ohio Health Group HMO |
$3,648.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$973.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$632.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,508.23
|
| Rate for Payer: PHCS Commercial |
$4,670.65
|
| Rate for Payer: United Healthcare All Payer |
$4,281.43
|
|
