|
VIBRAMYCIN (DOXYCYC 100MG/10ML
|
Facility
|
OP
|
$131.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$125.91 |
| Rate for Payer: Aetna Commercial |
$100.99
|
| Rate for Payer: Anthem Medicaid |
$45.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.30
|
| Rate for Payer: Cash Price |
$65.58
|
| Rate for Payer: Cigna Commercial |
$108.86
|
| Rate for Payer: First Health Commercial |
$124.60
|
| Rate for Payer: Humana Commercial |
$111.49
|
| Rate for Payer: Humana KY Medicaid |
$45.11
|
| Rate for Payer: Kentucky WC Medicaid |
$45.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.42
|
| Rate for Payer: Ohio Health Group HMO |
$98.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.66
|
| Rate for Payer: PHCS Commercial |
$125.91
|
| Rate for Payer: United Healthcare All Payer |
$115.42
|
|
|
VIBRAMYCIN (DOXYCYC 100MG/10ML
|
Facility
|
IP
|
$131.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$125.91 |
| Rate for Payer: Aetna Commercial |
$100.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.30
|
| Rate for Payer: Cash Price |
$65.58
|
| Rate for Payer: Cigna Commercial |
$108.86
|
| Rate for Payer: First Health Commercial |
$124.60
|
| Rate for Payer: Humana Commercial |
$111.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.42
|
| Rate for Payer: Ohio Health Group HMO |
$98.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.66
|
| Rate for Payer: PHCS Commercial |
$125.91
|
| Rate for Payer: United Healthcare All Payer |
$115.42
|
|
|
VIBRAMYCIN(DOXYCYCL 100MG/1TAB
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 53489012005
|
| Hospital Charge Code |
25001666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
VIBRAMYCIN(DOXYCYCL 100MG/1TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 53489012005
|
| Hospital Charge Code |
25001666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
VICI STENT 12*120*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 12*120*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 12*90*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 12*90*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 14*120*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 14*120*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 14*60*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 14*60*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 14*90*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 14*90*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 16*120*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 16*120*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 16*60*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 16*60*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 16*90*100
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VICI STENT 16*90*100
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
VIDAZA 100MG/4ML VIAL
|
Facility
|
IP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25003907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$414.64 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$988.76
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIDAZA 100MG/4ML VIAL
|
Facility
|
OP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25003907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$414.64 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem Medicaid |
$1,096.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Humana KY Medicaid |
$1,096.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,108.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,118.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$988.76
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIDAZA 1 MG/100MG VIAL
|
Facility
|
OP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25002560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$414.64 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem Medicaid |
$1,096.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Humana KY Medicaid |
$1,096.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,108.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,118.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$988.76
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIDAZA 1 MG/100MG VIAL
|
Facility
|
IP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25002560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$414.64 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$988.76
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIGAMOX 0.5%(MOXIFOX HCL) SOL
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 68180042201
|
| Hospital Charge Code |
25003575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.17
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna Commercial |
$1.24
|
| Rate for Payer: First Health Commercial |
$1.42
|
| Rate for Payer: Humana Commercial |
$1.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.32
|
| Rate for Payer: Ohio Health Group HMO |
$1.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.47
|
| Rate for Payer: PHCS Commercial |
$1.44
|
| Rate for Payer: United Healthcare All Payer |
$1.32
|
|
