|
VALISONE 0.1% CREAM 45GRM
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
NDC 168004046
|
| Hospital Charge Code |
25001643
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| 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 |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.80
|
| 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
|
|
|
VALISONE 0.1% CREAM 45GRM
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
NDC 168004046
|
| Hospital Charge Code |
25001643
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| 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 |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.80
|
| 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
|
|
|
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 |
$1.95 |
| 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 |
$5.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.48
|
| 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 |
$1.95 |
| 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 |
$5.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.48
|
| Rate for Payer: PHCS Commercial |
$6.23
|
| Rate for Payer: United Healthcare All Payer |
$5.71
|
|
|
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 |
$32.60 |
| 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 |
$86.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.98
|
| Rate for Payer: PHCS Commercial |
$104.31
|
| Rate for Payer: United Healthcare All Payer |
$95.62
|
|
|
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 |
$32.60 |
| 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 |
$86.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.98
|
| Rate for Payer: PHCS Commercial |
$104.31
|
| Rate for Payer: United Healthcare All Payer |
$95.62
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Professional
|
Both
|
$54.33
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
63600191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$32.60 |
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: Ambetter Exchange |
$6.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$6.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$6.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.40
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$6.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.17
|
| Rate for Payer: Multiplan PHCS |
$32.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8.02
|
| Rate for Payer: UHCCP Medicaid |
$19.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$6.17
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Facility
|
IP
|
$54.33
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
63600191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$52.16 |
| Rate for Payer: Aetna Commercial |
$41.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.38
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cigna Commercial |
$45.09
|
| Rate for Payer: First Health Commercial |
$51.61
|
| Rate for Payer: Humana Commercial |
$46.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.81
|
| Rate for Payer: Ohio Health Group HMO |
$40.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.49
|
| Rate for Payer: PHCS Commercial |
$52.16
|
| Rate for Payer: United Healthcare All Payer |
$47.81
|
|
|
VALIUM 5 MG (10MG/2ML VL)
|
Facility
|
OP
|
$54.33
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
63600191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$52.16 |
| Rate for Payer: Aetna Commercial |
$41.83
|
| Rate for Payer: Anthem Medicaid |
$18.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.38
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cigna Commercial |
$45.09
|
| Rate for Payer: First Health Commercial |
$51.61
|
| Rate for Payer: Humana Commercial |
$46.18
|
| Rate for Payer: Humana KY Medicaid |
$18.68
|
| Rate for Payer: Kentucky WC Medicaid |
$18.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.81
|
| Rate for Payer: Ohio Health Group HMO |
$40.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.49
|
| Rate for Payer: PHCS Commercial |
$52.16
|
| Rate for Payer: United Healthcare All Payer |
$47.81
|
|
|
VALIUM 5 MG (10MG/2ML VL)(T
|
Facility
|
OP
|
$54.33
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
636T0191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$52.16 |
| Rate for Payer: Aetna Commercial |
$41.83
|
| Rate for Payer: Anthem Medicaid |
$18.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.38
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cigna Commercial |
$45.09
|
| Rate for Payer: First Health Commercial |
$51.61
|
| Rate for Payer: Humana Commercial |
$46.18
|
| Rate for Payer: Humana KY Medicaid |
$18.68
|
| Rate for Payer: Kentucky WC Medicaid |
$18.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.81
|
| Rate for Payer: Ohio Health Group HMO |
$40.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.49
|
| Rate for Payer: PHCS Commercial |
$52.16
|
| Rate for Payer: United Healthcare All Payer |
$47.81
|
|
|
VALIUM 5 MG (10MG/2ML VL)(T
|
Facility
|
IP
|
$54.33
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
636T0191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$52.16 |
| Rate for Payer: Aetna Commercial |
$41.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.38
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cigna Commercial |
$45.09
|
| Rate for Payer: First Health Commercial |
$51.61
|
| Rate for Payer: Humana Commercial |
$46.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.81
|
| Rate for Payer: Ohio Health Group HMO |
$40.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.49
|
| Rate for Payer: PHCS Commercial |
$52.16
|
| Rate for Payer: United Healthcare All Payer |
$47.81
|
|
|
VALIUM 5MG/5ML ORAL LIQUID
|
Facility
|
OP
|
$60.58
|
|
|
Service Code
|
NDC 54318863
|
| Hospital Charge Code |
25001645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.17 |
| 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 |
$48.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.80
|
| 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 |
$18.17 |
| 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 |
$48.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.80
|
| Rate for Payer: PHCS Commercial |
$58.16
|
| Rate for Payer: United Healthcare All Payer |
$53.31
|
|
|
VALIUM (DIAZEPAM) 5MG/1TAB
|
Facility
|
OP
|
$60.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25002774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$57.65 |
| Rate for Payer: Aetna Commercial |
$46.24
|
| Rate for Payer: Anthem Medicaid |
$20.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.84
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cigna Commercial |
$49.84
|
| Rate for Payer: First Health Commercial |
$57.05
|
| Rate for Payer: Humana Commercial |
$51.04
|
| Rate for Payer: Humana KY Medicaid |
$20.65
|
| Rate for Payer: Kentucky WC Medicaid |
$20.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.84
|
| Rate for Payer: Ohio Health Group HMO |
$45.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.43
|
| Rate for Payer: PHCS Commercial |
$57.65
|
| Rate for Payer: United Healthcare All Payer |
$52.84
|
|
|
VALIUM (DIAZEPAM) 5MG/1TAB
|
Facility
|
IP
|
$60.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25002774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$57.65 |
| Rate for Payer: Aetna Commercial |
$46.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.84
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cigna Commercial |
$49.84
|
| Rate for Payer: First Health Commercial |
$57.05
|
| Rate for Payer: Humana Commercial |
$51.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.84
|
| Rate for Payer: Ohio Health Group HMO |
$45.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.43
|
| Rate for Payer: PHCS Commercial |
$57.65
|
| Rate for Payer: United Healthcare All Payer |
$52.84
|
|
|
VAL KREULOCK SCREW TI 2.4X16
|
Facility
|
IP
|
$3,161.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.47 |
| Max. Negotiated Rate |
$3,035.10 |
| Rate for Payer: Aetna Commercial |
$2,434.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.02
|
| Rate for Payer: Cash Price |
$1,580.78
|
| Rate for Payer: Cigna Commercial |
$2,624.09
|
| Rate for Payer: First Health Commercial |
$3,003.48
|
| Rate for Payer: Humana Commercial |
$2,687.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.17
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.48
|
| Rate for Payer: PHCS Commercial |
$3,035.10
|
| Rate for Payer: United Healthcare All Payer |
$2,782.17
|
|
|
VAL KREULOCK SCREW TI 2.4X16
|
Facility
|
OP
|
$3,161.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.47 |
| Max. Negotiated Rate |
$3,035.10 |
| Rate for Payer: Aetna Commercial |
$2,434.40
|
| Rate for Payer: Anthem Medicaid |
$1,087.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.02
|
| Rate for Payer: Cash Price |
$1,580.78
|
| Rate for Payer: Cigna Commercial |
$2,624.09
|
| Rate for Payer: First Health Commercial |
$3,003.48
|
| Rate for Payer: Humana Commercial |
$2,687.33
|
| Rate for Payer: Humana KY Medicaid |
$1,087.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,098.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,109.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.17
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.48
|
| Rate for Payer: PHCS Commercial |
$3,035.10
|
| Rate for Payer: United Healthcare All Payer |
$2,782.17
|
|
|
VALPROIC ACID
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
HCPCS 80164
|
| Hospital Charge Code |
30000026
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Aetna Commercial |
$76.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$82.17
|
| Rate for Payer: First Health Commercial |
$94.05
|
| Rate for Payer: Humana Commercial |
$84.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.12
|
| Rate for Payer: Ohio Health Group HMO |
$74.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.31
|
| Rate for Payer: PHCS Commercial |
$95.04
|
| Rate for Payer: United Healthcare All Payer |
$87.12
|
|
|
VALPROIC ACID
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
HCPCS 80164
|
| Hospital Charge Code |
30000026
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.54 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Aetna Commercial |
$76.23
|
| Rate for Payer: Anthem Medicaid |
$13.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.54
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$82.17
|
| Rate for Payer: First Health Commercial |
$94.05
|
| Rate for Payer: Humana Commercial |
$84.15
|
| Rate for Payer: Humana KY Medicaid |
$13.54
|
| Rate for Payer: Humana Medicare Advantage |
$13.54
|
| Rate for Payer: Kentucky WC Medicaid |
$13.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.12
|
| Rate for Payer: Ohio Health Group HMO |
$74.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.31
|
| Rate for Payer: PHCS Commercial |
$95.04
|
| Rate for Payer: United Healthcare All Payer |
$87.12
|
|
|
VAL SCREW TI 2.0 X 40MM
|
Facility
|
OP
|
$1,832.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem Medicaid |
$630.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Humana KY Medicaid |
$630.02
|
| Rate for Payer: Kentucky WC Medicaid |
$636.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$642.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
VAL SCREW TI 2.0 X 40MM
|
Facility
|
IP
|
$1,832.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
VALSTAR 200 MG [800MG PKG
|
Facility
|
IP
|
$10,083.86
|
|
|
Service Code
|
HCPCS J9357
|
| Hospital Charge Code |
25002688
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,025.16 |
| Max. Negotiated Rate |
$9,680.51 |
| Rate for Payer: Aetna Commercial |
$7,764.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,865.41
|
| Rate for Payer: Cash Price |
$5,041.93
|
| Rate for Payer: Cigna Commercial |
$8,369.60
|
| Rate for Payer: First Health Commercial |
$9,579.67
|
| Rate for Payer: Humana Commercial |
$8,571.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,268.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,441.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,025.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,873.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,562.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,067.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,772.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,957.86
|
| Rate for Payer: PHCS Commercial |
$9,680.51
|
| Rate for Payer: United Healthcare All Payer |
$8,873.80
|
|
|
VALSTAR 200 MG [800MG PKG
|
Facility
|
OP
|
$10,083.86
|
|
|
Service Code
|
HCPCS J9357
|
| Hospital Charge Code |
25002688
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,376.79 |
| Max. Negotiated Rate |
$9,680.51 |
| Rate for Payer: Aetna Commercial |
$7,764.57
|
| Rate for Payer: Anthem Medicaid |
$3,467.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,376.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,865.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,927.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,858.67
|
| Rate for Payer: Cash Price |
$5,041.93
|
| Rate for Payer: Cash Price |
$5,041.93
|
| Rate for Payer: Cigna Commercial |
$8,369.60
|
| Rate for Payer: First Health Commercial |
$9,579.67
|
| Rate for Payer: Humana Commercial |
$8,571.28
|
| Rate for Payer: Humana KY Medicaid |
$3,467.84
|
| Rate for Payer: Humana Medicare Advantage |
$1,376.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,503.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,268.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,441.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,652.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,537.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,873.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,562.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,067.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,772.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,957.86
|
| Rate for Payer: PHCS Commercial |
$9,680.51
|
| Rate for Payer: United Healthcare All Payer |
$8,873.80
|
|
|
VALTREX(VALACYCLOV 500MG/1CAP
|
Facility
|
OP
|
$5.01
|
|
|
Service Code
|
NDC 31722070430
|
| Hospital Charge Code |
25001647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Aetna Commercial |
$3.86
|
| Rate for Payer: Anthem Medicaid |
$1.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.91
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna Commercial |
$4.16
|
| Rate for Payer: First Health Commercial |
$4.76
|
| Rate for Payer: Humana Commercial |
$4.26
|
| Rate for Payer: Humana KY Medicaid |
$1.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.41
|
| Rate for Payer: Ohio Health Group HMO |
$3.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$4.81
|
| Rate for Payer: United Healthcare All Payer |
$4.41
|
|
|
VALTREX(VALACYCLOV 500MG/1CAP
|
Facility
|
IP
|
$5.01
|
|
|
Service Code
|
NDC 31722070430
|
| Hospital Charge Code |
25001647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Aetna Commercial |
$3.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.91
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna Commercial |
$4.16
|
| Rate for Payer: First Health Commercial |
$4.76
|
| Rate for Payer: Humana Commercial |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.41
|
| Rate for Payer: Ohio Health Group HMO |
$3.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$4.81
|
| Rate for Payer: United Healthcare All Payer |
$4.41
|
|
