|
VALVULOPLASTY
|
Facility
|
IP
|
$5,600.00
|
|
|
Service Code
|
HCPCS 33464
|
| Hospital Charge Code |
76101293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,680.00 |
| Max. Negotiated Rate |
$5,376.00 |
| Rate for Payer: Aetna Commercial |
$4,312.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$4,648.00
|
| Rate for Payer: First Health Commercial |
$5,320.00
|
| Rate for Payer: Humana Commercial |
$4,760.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,132.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,872.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,864.00
|
| Rate for Payer: PHCS Commercial |
$5,376.00
|
| Rate for Payer: United Healthcare All Payer |
$4,928.00
|
|
|
VALVULOPLASTY
|
Facility
|
OP
|
$5,600.00
|
|
|
Service Code
|
HCPCS 33464
|
| Hospital Charge Code |
76101293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,680.00 |
| Max. Negotiated Rate |
$5,376.00 |
| Rate for Payer: Aetna Commercial |
$4,312.00
|
| Rate for Payer: Anthem Medicaid |
$1,925.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$4,648.00
|
| Rate for Payer: First Health Commercial |
$5,320.00
|
| Rate for Payer: Humana Commercial |
$4,760.00
|
| Rate for Payer: Humana KY Medicaid |
$1,925.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,945.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,132.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,964.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,872.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,864.00
|
| Rate for Payer: PHCS Commercial |
$5,376.00
|
| Rate for Payer: United Healthcare All Payer |
$4,928.00
|
|
|
VALVULOPLASTY
|
Professional
|
Both
|
$5,600.00
|
|
|
Service Code
|
HCPCS 33464
|
| Hospital Charge Code |
76101293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,779.97 |
| Max. Negotiated Rate |
$4,025.17 |
| Rate for Payer: Aetna Commercial |
$4,025.17
|
| Rate for Payer: Ambetter Exchange |
$2,286.41
|
| Rate for Payer: Anthem Medicaid |
$1,779.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,286.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,286.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,743.69
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$3,674.36
|
| Rate for Payer: Healthspan PPO |
$3,957.53
|
| Rate for Payer: Humana Medicaid |
$1,779.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,446.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,286.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,286.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,815.57
|
| Rate for Payer: Molina Healthcare Passport |
$1,779.97
|
| Rate for Payer: Multiplan PHCS |
$3,360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,972.33
|
| Rate for Payer: UHCCP Medicaid |
$1,960.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,797.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,286.41
|
|
|
VALVULOPLASTY(P
|
Professional
|
Both
|
$5,600.00
|
|
|
Service Code
|
HCPCS 33464
|
| Hospital Charge Code |
761P1293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,779.97 |
| Max. Negotiated Rate |
$4,025.17 |
| Rate for Payer: Aetna Commercial |
$4,025.17
|
| Rate for Payer: Ambetter Exchange |
$2,286.41
|
| Rate for Payer: Anthem Medicaid |
$1,779.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,286.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,286.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,743.69
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$3,674.36
|
| Rate for Payer: Healthspan PPO |
$3,957.53
|
| Rate for Payer: Humana Medicaid |
$1,779.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,446.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,286.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,286.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,815.57
|
| Rate for Payer: Molina Healthcare Passport |
$1,779.97
|
| Rate for Payer: Multiplan PHCS |
$3,360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,972.33
|
| Rate for Payer: UHCCP Medicaid |
$1,960.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,797.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,286.41
|
|
|
VALVULOPLASTY TRICUSPID
|
Facility
|
IP
|
$5,350.00
|
|
|
Service Code
|
HCPCS 33463
|
| Hospital Charge Code |
76101292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,605.00 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,654.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,691.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
VALVULOPLASTY TRICUSPID
|
Professional
|
Both
|
$5,350.00
|
|
|
Service Code
|
HCPCS 33463
|
| Hospital Charge Code |
76101292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,729.79 |
| Max. Negotiated Rate |
$4,954.11 |
| Rate for Payer: Aetna Commercial |
$4,954.11
|
| Rate for Payer: Ambetter Exchange |
$2,883.98
|
| Rate for Payer: Anthem Medicaid |
$1,729.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,883.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,883.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,460.78
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,401.67
|
| Rate for Payer: Healthspan PPO |
$4,870.86
|
| Rate for Payer: Humana Medicaid |
$1,729.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4,342.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,883.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,883.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,764.39
|
| Rate for Payer: Molina Healthcare Passport |
$1,729.79
|
| Rate for Payer: Multiplan PHCS |
$3,210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,749.17
|
| Rate for Payer: UHCCP Medicaid |
$1,872.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,747.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,883.98
|
|
|
VALVULOPLASTY TRICUSPID
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS 33463
|
| Hospital Charge Code |
76101292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,605.00 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,654.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,691.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
VALVULOPLASTY TRICUSPID(P
|
Professional
|
Both
|
$5,350.00
|
|
|
Service Code
|
HCPCS 33463
|
| Hospital Charge Code |
761P1292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,729.79 |
| Max. Negotiated Rate |
$4,954.11 |
| Rate for Payer: Aetna Commercial |
$4,954.11
|
| Rate for Payer: Ambetter Exchange |
$2,883.98
|
| Rate for Payer: Anthem Medicaid |
$1,729.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,883.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,883.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,460.78
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,401.67
|
| Rate for Payer: Healthspan PPO |
$4,870.86
|
| Rate for Payer: Humana Medicaid |
$1,729.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4,342.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,883.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,883.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,764.39
|
| Rate for Payer: Molina Healthcare Passport |
$1,729.79
|
| Rate for Payer: Multiplan PHCS |
$3,210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,749.17
|
| Rate for Payer: UHCCP Medicaid |
$1,872.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,747.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,883.98
|
|
|
VANC 10 MG (1.25GM PRMX)Xellia
|
Facility
|
OP
|
$103.55
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna Commercial |
$79.73
|
| Rate for Payer: Anthem Medicaid |
$35.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.77
|
| Rate for Payer: Cash Price |
$51.77
|
| Rate for Payer: Cigna Commercial |
$85.95
|
| Rate for Payer: First Health Commercial |
$98.37
|
| Rate for Payer: Humana Commercial |
$88.02
|
| Rate for Payer: Humana KY Medicaid |
$35.61
|
| Rate for Payer: Kentucky WC Medicaid |
$35.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.12
|
| Rate for Payer: Ohio Health Group HMO |
$77.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.45
|
| Rate for Payer: PHCS Commercial |
$99.41
|
| Rate for Payer: United Healthcare All Payer |
$91.12
|
|
|
VANC 10 MG (1.25GM PRMX)Xellia
|
Facility
|
IP
|
$103.55
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna Commercial |
$79.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.77
|
| Rate for Payer: Cash Price |
$51.77
|
| Rate for Payer: Cigna Commercial |
$85.95
|
| Rate for Payer: First Health Commercial |
$98.37
|
| Rate for Payer: Humana Commercial |
$88.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.12
|
| Rate for Payer: Ohio Health Group HMO |
$77.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.45
|
| Rate for Payer: PHCS Commercial |
$99.41
|
| Rate for Payer: United Healthcare All Payer |
$91.12
|
|
|
VANC 10 MG (1.5GM PRMX)Xellia
|
Facility
|
OP
|
$125.35
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004449
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.60 |
| Max. Negotiated Rate |
$120.34 |
| Rate for Payer: Aetna Commercial |
$96.52
|
| Rate for Payer: Anthem Medicaid |
$43.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.77
|
| Rate for Payer: Cash Price |
$62.67
|
| Rate for Payer: Cigna Commercial |
$104.04
|
| Rate for Payer: First Health Commercial |
$119.08
|
| Rate for Payer: Humana Commercial |
$106.55
|
| Rate for Payer: Humana KY Medicaid |
$43.11
|
| Rate for Payer: Kentucky WC Medicaid |
$43.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.31
|
| Rate for Payer: Ohio Health Group HMO |
$94.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.49
|
| Rate for Payer: PHCS Commercial |
$120.34
|
| Rate for Payer: United Healthcare All Payer |
$110.31
|
|
|
VANC 10 MG (1.5GM PRMX)Xellia
|
Facility
|
IP
|
$125.35
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004449
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.60 |
| Max. Negotiated Rate |
$120.34 |
| Rate for Payer: Aetna Commercial |
$96.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.77
|
| Rate for Payer: Cash Price |
$62.67
|
| Rate for Payer: Cigna Commercial |
$104.04
|
| Rate for Payer: First Health Commercial |
$119.08
|
| Rate for Payer: Humana Commercial |
$106.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.31
|
| Rate for Payer: Ohio Health Group HMO |
$94.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.49
|
| Rate for Payer: PHCS Commercial |
$120.34
|
| Rate for Payer: United Healthcare All Payer |
$110.31
|
|
|
VANC 10 MG (1GM PRMX)Xellia
|
Facility
|
IP
|
$147.53
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.26 |
| Max. Negotiated Rate |
$141.63 |
| Rate for Payer: Aetna Commercial |
$113.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.07
|
| Rate for Payer: Cash Price |
$73.76
|
| Rate for Payer: Cigna Commercial |
$122.45
|
| Rate for Payer: First Health Commercial |
$140.15
|
| Rate for Payer: Humana Commercial |
$125.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.83
|
| Rate for Payer: Ohio Health Group HMO |
$110.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$128.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.80
|
| Rate for Payer: PHCS Commercial |
$141.63
|
| Rate for Payer: United Healthcare All Payer |
$129.83
|
|
|
VANC 10 MG (1GM PRMX)Xellia
|
Facility
|
OP
|
$147.53
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.26 |
| Max. Negotiated Rate |
$141.63 |
| Rate for Payer: Aetna Commercial |
$113.60
|
| Rate for Payer: Anthem Medicaid |
$50.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.07
|
| Rate for Payer: Cash Price |
$73.76
|
| Rate for Payer: Cigna Commercial |
$122.45
|
| Rate for Payer: First Health Commercial |
$140.15
|
| Rate for Payer: Humana Commercial |
$125.40
|
| Rate for Payer: Humana KY Medicaid |
$50.74
|
| Rate for Payer: Kentucky WC Medicaid |
$51.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.83
|
| Rate for Payer: Ohio Health Group HMO |
$110.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$128.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.80
|
| Rate for Payer: PHCS Commercial |
$141.63
|
| Rate for Payer: United Healthcare All Payer |
$129.83
|
|
|
VANC 10 MG (750MG PRMX)Xellia
|
Facility
|
OP
|
$65.40
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.62 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Anthem Medicaid |
$22.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.01
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: First Health Commercial |
$62.13
|
| Rate for Payer: Humana Commercial |
$55.59
|
| Rate for Payer: Humana KY Medicaid |
$22.49
|
| Rate for Payer: Kentucky WC Medicaid |
$22.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.55
|
| Rate for Payer: Ohio Health Group HMO |
$49.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.13
|
| Rate for Payer: PHCS Commercial |
$62.78
|
| Rate for Payer: United Healthcare All Payer |
$57.55
|
|
|
VANC 10 MG (750MG PRMX)Xellia
|
Facility
|
IP
|
$65.40
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
25004453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.62 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.01
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: First Health Commercial |
$62.13
|
| Rate for Payer: Humana Commercial |
$55.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.55
|
| Rate for Payer: Ohio Health Group HMO |
$49.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.13
|
| Rate for Payer: PHCS Commercial |
$62.78
|
| Rate for Payer: United Healthcare All Payer |
$57.55
|
|
|
VANCOMYCIN 10 MG (1.25GMIVPB)
|
Facility
|
OP
|
$181.59
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.48 |
| Max. Negotiated Rate |
$174.33 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Anthem Medicaid |
$62.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.64
|
| Rate for Payer: Cash Price |
$90.80
|
| Rate for Payer: Cigna Commercial |
$150.72
|
| Rate for Payer: First Health Commercial |
$172.51
|
| Rate for Payer: Humana Commercial |
$154.35
|
| Rate for Payer: Humana KY Medicaid |
$62.45
|
| Rate for Payer: Kentucky WC Medicaid |
$63.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.80
|
| Rate for Payer: Ohio Health Group HMO |
$136.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.30
|
| Rate for Payer: PHCS Commercial |
$174.33
|
| Rate for Payer: United Healthcare All Payer |
$159.80
|
|
|
VANCOMYCIN 10 MG (1.25GMIVPB)
|
Facility
|
IP
|
$181.59
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.48 |
| Max. Negotiated Rate |
$174.33 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.64
|
| Rate for Payer: Cash Price |
$90.80
|
| Rate for Payer: Cigna Commercial |
$150.72
|
| Rate for Payer: First Health Commercial |
$172.51
|
| Rate for Payer: Humana Commercial |
$154.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.80
|
| Rate for Payer: Ohio Health Group HMO |
$136.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.30
|
| Rate for Payer: PHCS Commercial |
$174.33
|
| Rate for Payer: United Healthcare All Payer |
$159.80
|
|
|
VANCOMYCIN (10mg) (1 GM/20ML)
|
Facility
|
OP
|
$33.04
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$31.72 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Commercial |
$94.74
|
| Rate for Payer: Aetna Commercial |
$70.10
|
| Rate for Payer: Anthem Medicaid |
$31.31
|
| Rate for Payer: Anthem Medicaid |
$11.36
|
| Rate for Payer: Anthem Medicaid |
$42.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.97
|
| Rate for Payer: Cash Price |
$45.52
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cigna Commercial |
$27.42
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Cigna Commercial |
$75.56
|
| Rate for Payer: First Health Commercial |
$86.49
|
| Rate for Payer: First Health Commercial |
$116.89
|
| Rate for Payer: First Health Commercial |
$31.39
|
| Rate for Payer: Humana Commercial |
$77.38
|
| Rate for Payer: Humana Commercial |
$104.58
|
| Rate for Payer: Humana Commercial |
$28.08
|
| Rate for Payer: Humana KY Medicaid |
$11.36
|
| Rate for Payer: Humana KY Medicaid |
$42.31
|
| Rate for Payer: Humana KY Medicaid |
$31.31
|
| Rate for Payer: Kentucky WC Medicaid |
$31.63
|
| Rate for Payer: Kentucky WC Medicaid |
$11.48
|
| Rate for Payer: Kentucky WC Medicaid |
$42.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.12
|
| Rate for Payer: Ohio Health Group HMO |
$68.28
|
| Rate for Payer: Ohio Health Group HMO |
$92.28
|
| Rate for Payer: Ohio Health Group HMO |
$24.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.82
|
| Rate for Payer: PHCS Commercial |
$118.12
|
| Rate for Payer: PHCS Commercial |
$87.40
|
| Rate for Payer: PHCS Commercial |
$31.72
|
| Rate for Payer: United Healthcare All Payer |
$80.12
|
| Rate for Payer: United Healthcare All Payer |
$29.08
|
| Rate for Payer: United Healthcare All Payer |
$108.28
|
|
|
VANCOMYCIN (10mg) (1 GM/20ML)
|
Facility
|
IP
|
$123.04
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.91 |
| Max. Negotiated Rate |
$118.12 |
| Rate for Payer: Aetna Commercial |
$94.74
|
| Rate for Payer: Aetna Commercial |
$70.10
|
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.01
|
| Rate for Payer: Cash Price |
$45.52
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cigna Commercial |
$27.42
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Cigna Commercial |
$75.56
|
| Rate for Payer: First Health Commercial |
$86.49
|
| Rate for Payer: First Health Commercial |
$116.89
|
| Rate for Payer: First Health Commercial |
$31.39
|
| Rate for Payer: Humana Commercial |
$77.38
|
| Rate for Payer: Humana Commercial |
$104.58
|
| Rate for Payer: Humana Commercial |
$28.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.08
|
| Rate for Payer: Ohio Health Group HMO |
$92.28
|
| Rate for Payer: Ohio Health Group HMO |
$24.78
|
| Rate for Payer: Ohio Health Group HMO |
$68.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.82
|
| Rate for Payer: PHCS Commercial |
$118.12
|
| Rate for Payer: PHCS Commercial |
$87.40
|
| Rate for Payer: PHCS Commercial |
$31.72
|
| Rate for Payer: United Healthcare All Payer |
$29.08
|
| Rate for Payer: United Healthcare All Payer |
$108.28
|
| Rate for Payer: United Healthcare All Payer |
$80.12
|
|
|
VANCOMYCIN (10MG) 1GR POWDER
|
Facility
|
OP
|
$87.42
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002414
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$83.92 |
| Rate for Payer: Aetna Commercial |
$67.31
|
| Rate for Payer: Anthem Medicaid |
$30.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.19
|
| Rate for Payer: Cash Price |
$43.71
|
| Rate for Payer: Cigna Commercial |
$72.56
|
| Rate for Payer: First Health Commercial |
$83.05
|
| Rate for Payer: Humana Commercial |
$74.31
|
| Rate for Payer: Humana KY Medicaid |
$30.06
|
| Rate for Payer: Kentucky WC Medicaid |
$30.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.93
|
| Rate for Payer: Ohio Health Group HMO |
$65.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.32
|
| Rate for Payer: PHCS Commercial |
$83.92
|
| Rate for Payer: United Healthcare All Payer |
$76.93
|
|
|
VANCOMYCIN (10MG) 1GR POWDER
|
Facility
|
IP
|
$87.42
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002414
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$83.92 |
| Rate for Payer: Aetna Commercial |
$67.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.19
|
| Rate for Payer: Cash Price |
$43.71
|
| Rate for Payer: Cigna Commercial |
$72.56
|
| Rate for Payer: First Health Commercial |
$83.05
|
| Rate for Payer: Humana Commercial |
$74.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.93
|
| Rate for Payer: Ohio Health Group HMO |
$65.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.32
|
| Rate for Payer: PHCS Commercial |
$83.92
|
| Rate for Payer: United Healthcare All Payer |
$76.93
|
|
|
VANCOMYCIN (10mg)2GM PREMIX
|
Facility
|
IP
|
$203.45
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002413
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.03 |
| Max. Negotiated Rate |
$195.31 |
| Rate for Payer: Aetna Commercial |
$156.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.69
|
| Rate for Payer: Cash Price |
$101.72
|
| Rate for Payer: Cigna Commercial |
$168.86
|
| Rate for Payer: First Health Commercial |
$193.28
|
| Rate for Payer: Humana Commercial |
$172.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$179.04
|
| Rate for Payer: Ohio Health Group HMO |
$152.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$177.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.38
|
| Rate for Payer: PHCS Commercial |
$195.31
|
| Rate for Payer: United Healthcare All Payer |
$179.04
|
|
|
VANCOMYCIN (10mg)2GM PREMIX
|
Facility
|
OP
|
$203.45
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002413
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.03 |
| Max. Negotiated Rate |
$195.31 |
| Rate for Payer: Aetna Commercial |
$156.66
|
| Rate for Payer: Anthem Medicaid |
$69.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.69
|
| Rate for Payer: Cash Price |
$101.72
|
| Rate for Payer: Cigna Commercial |
$168.86
|
| Rate for Payer: First Health Commercial |
$193.28
|
| Rate for Payer: Humana Commercial |
$172.93
|
| Rate for Payer: Humana KY Medicaid |
$69.97
|
| Rate for Payer: Kentucky WC Medicaid |
$70.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$179.04
|
| Rate for Payer: Ohio Health Group HMO |
$152.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$177.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.38
|
| Rate for Payer: PHCS Commercial |
$195.31
|
| Rate for Payer: United Healthcare All Payer |
$179.04
|
|
|
VANCOMYCIN (10mg) 500MG/10ML
|
Facility
|
IP
|
$78.95
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
25002409
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$75.79 |
| Rate for Payer: Aetna Commercial |
$60.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.58
|
| Rate for Payer: Cash Price |
$39.48
|
| Rate for Payer: Cigna Commercial |
$65.53
|
| Rate for Payer: First Health Commercial |
$75.00
|
| Rate for Payer: Humana Commercial |
$67.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.48
|
| Rate for Payer: Ohio Health Group HMO |
$59.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.48
|
| Rate for Payer: PHCS Commercial |
$75.79
|
| Rate for Payer: United Healthcare All Payer |
$69.48
|
|
