|
VIPERWIRE .017 335CM
|
Facility
|
IP
|
$1,945.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.85 |
| Max. Negotiated Rate |
$1,867.20 |
| Rate for Payer: Aetna Commercial |
$1,497.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.10
|
| Rate for Payer: Cash Price |
$972.50
|
| Rate for Payer: Cigna Commercial |
$1,614.35
|
| Rate for Payer: First Health Commercial |
$1,847.75
|
| Rate for Payer: Humana Commercial |
$1,653.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,594.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,435.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,711.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,458.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$602.95
|
| Rate for Payer: PHCS Commercial |
$1,867.20
|
| Rate for Payer: United Healthcare All Payer |
$1,711.60
|
|
|
VIPERWIRE .017 335CM
|
Facility
|
OP
|
$1,945.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.85 |
| Max. Negotiated Rate |
$1,867.20 |
| Rate for Payer: Aetna Commercial |
$1,497.65
|
| Rate for Payer: Anthem Medicaid |
$668.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.10
|
| Rate for Payer: Cash Price |
$972.50
|
| Rate for Payer: Cigna Commercial |
$1,614.35
|
| Rate for Payer: First Health Commercial |
$1,847.75
|
| Rate for Payer: Humana Commercial |
$1,653.25
|
| Rate for Payer: Humana KY Medicaid |
$668.89
|
| Rate for Payer: Kentucky WC Medicaid |
$675.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,594.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,435.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$682.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,711.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,458.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$602.95
|
| Rate for Payer: PHCS Commercial |
$1,867.20
|
| Rate for Payer: United Healthcare All Payer |
$1,711.60
|
|
|
VIPERWIRE FLX GEN 2 .018*335CM
|
Facility
|
OP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem Medicaid |
$692.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Humana KY Medicaid |
$692.96
|
| Rate for Payer: Kentucky WC Medicaid |
$700.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$706.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
VIPERWIRE FLX GEN 2 .018*335CM
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
VIRAL ILLNESS WITH MCC
|
Facility
|
IP
|
$19,183.91
|
|
|
Service Code
|
MSDRG 865
|
| Min. Negotiated Rate |
$13,017.65 |
| Max. Negotiated Rate |
$19,183.91 |
| Rate for Payer: Anthem Medicaid |
$13,017.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,702.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,183.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,498.77
|
| Rate for Payer: Humana KY Medicaid |
$13,017.65
|
| Rate for Payer: Humana Medicare Advantage |
$13,702.79
|
| Rate for Payer: Kentucky WC Medicaid |
$13,147.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,443.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,278.00
|
|
|
VIRAL ILLNESS WITHOUT MCC
|
Facility
|
IP
|
$10,735.44
|
|
|
Service Code
|
MSDRG 866
|
| Min. Negotiated Rate |
$7,284.76 |
| Max. Negotiated Rate |
$10,735.44 |
| Rate for Payer: Anthem Medicaid |
$7,284.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,668.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,735.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,352.03
|
| Rate for Payer: Humana KY Medicaid |
$7,284.76
|
| Rate for Payer: Humana Medicare Advantage |
$7,668.17
|
| Rate for Payer: Kentucky WC Medicaid |
$7,357.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,201.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,430.46
|
|
|
VIRAL MENINGITIS WITH CC/MCC
|
Facility
|
IP
|
$22,388.04
|
|
|
Service Code
|
MSDRG 075
|
| Min. Negotiated Rate |
$15,191.89 |
| Max. Negotiated Rate |
$22,388.04 |
| Rate for Payer: Anthem Medicaid |
$15,191.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,991.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,388.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,588.47
|
| Rate for Payer: Humana KY Medicaid |
$15,191.89
|
| Rate for Payer: Humana Medicare Advantage |
$15,991.46
|
| Rate for Payer: Kentucky WC Medicaid |
$15,343.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,189.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,495.72
|
|
|
VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$10,791.59
|
|
|
Service Code
|
MSDRG 076
|
| Min. Negotiated Rate |
$7,322.87 |
| Max. Negotiated Rate |
$10,791.59 |
| Rate for Payer: Anthem Medicaid |
$7,322.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,708.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,791.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,406.18
|
| Rate for Payer: Humana KY Medicaid |
$7,322.87
|
| Rate for Payer: Humana Medicare Advantage |
$7,708.28
|
| Rate for Payer: Kentucky WC Medicaid |
$7,396.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,249.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,469.32
|
|
|
VIREAD 150 MG TABLET
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 61958040401
|
| Hospital Charge Code |
25001673
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.78
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 150 MG TABLET
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 61958040401
|
| Hospital Charge Code |
25001673
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Humana KY Medicaid |
$26.38
|
| Rate for Payer: Kentucky WC Medicaid |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.78
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 200 MG TABLET
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 61958040501
|
| Hospital Charge Code |
25001674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Humana KY Medicaid |
$26.38
|
| Rate for Payer: Kentucky WC Medicaid |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.78
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 200 MG TABLET
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 61958040501
|
| Hospital Charge Code |
25001674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.78
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 250 MG TABLET
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 61958040601
|
| Hospital Charge Code |
25001675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.78
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 250 MG TABLET
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 61958040601
|
| Hospital Charge Code |
25001675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Humana KY Medicaid |
$26.38
|
| Rate for Payer: Kentucky WC Medicaid |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.78
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 300MG TABLET
|
Facility
|
IP
|
$79.78
|
|
|
Service Code
|
NDC 61958040101
|
| Hospital Charge Code |
25001676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$76.59 |
| Rate for Payer: Aetna Commercial |
$61.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.23
|
| Rate for Payer: Cash Price |
$39.89
|
| Rate for Payer: Cigna Commercial |
$66.22
|
| Rate for Payer: First Health Commercial |
$75.79
|
| Rate for Payer: Humana Commercial |
$67.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.21
|
| Rate for Payer: Ohio Health Group HMO |
$59.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.73
|
| Rate for Payer: PHCS Commercial |
$76.59
|
| Rate for Payer: United Healthcare All Payer |
$70.21
|
|
|
VIREAD 300MG TABLET
|
Facility
|
OP
|
$79.78
|
|
|
Service Code
|
NDC 61958040101
|
| Hospital Charge Code |
25001676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$76.59 |
| Rate for Payer: Anthem Medicaid |
$27.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.23
|
| Rate for Payer: Cash Price |
$39.89
|
| Rate for Payer: Cigna Commercial |
$66.22
|
| Rate for Payer: First Health Commercial |
$75.79
|
| Rate for Payer: Humana Commercial |
$67.81
|
| Rate for Payer: Humana KY Medicaid |
$27.44
|
| Rate for Payer: Kentucky WC Medicaid |
$27.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.21
|
| Rate for Payer: Ohio Health Group HMO |
$59.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.73
|
| Rate for Payer: PHCS Commercial |
$76.59
|
| Rate for Payer: United Healthcare All Payer |
$70.21
|
| Rate for Payer: Aetna Commercial |
$61.43
|
|
|
VIROPTIC 1% EYE DROPS
|
Facility
|
OP
|
$4.09
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
25001677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Anthem Medicaid |
$1.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna Commercial |
$3.39
|
| Rate for Payer: First Health Commercial |
$3.89
|
| Rate for Payer: Humana Commercial |
$3.48
|
| Rate for Payer: Humana KY Medicaid |
$1.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.60
|
| Rate for Payer: Ohio Health Group HMO |
$3.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.27
|
| Rate for Payer: PHCS Commercial |
$3.93
|
| Rate for Payer: United Healthcare All Payer |
$3.60
|
|
|
VIROPTIC 1% EYE DROPS
|
Facility
|
IP
|
$4.09
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
25001677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna Commercial |
$3.39
|
| Rate for Payer: First Health Commercial |
$3.89
|
| Rate for Payer: Humana Commercial |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.60
|
| Rate for Payer: Ohio Health Group HMO |
$3.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.27
|
| Rate for Payer: PHCS Commercial |
$3.93
|
| Rate for Payer: United Healthcare All Payer |
$3.60
|
|
|
VIRTUOSO II DR D274DRG
|
Facility
|
IP
|
$81,700.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,621.00 |
| Max. Negotiated Rate |
$78,432.00 |
| Rate for Payer: Aetna Commercial |
$62,909.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63,726.00
|
| Rate for Payer: Cash Price |
$40,850.00
|
| Rate for Payer: Cigna Commercial |
$67,811.00
|
| Rate for Payer: First Health Commercial |
$77,615.00
|
| Rate for Payer: Humana Commercial |
$69,445.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66,994.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60,294.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$71,896.00
|
| Rate for Payer: Ohio Health Group HMO |
$61,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,621.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,327.00
|
| Rate for Payer: PHCS Commercial |
$78,432.00
|
| Rate for Payer: United Healthcare All Payer |
$71,896.00
|
|
|
VIRTUOSO II DR D274DRG
|
Facility
|
OP
|
$81,700.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,621.00 |
| Max. Negotiated Rate |
$78,432.00 |
| Rate for Payer: First Health Commercial |
$77,615.00
|
| Rate for Payer: Humana Commercial |
$69,445.00
|
| Rate for Payer: Humana KY Medicaid |
$28,096.63
|
| Rate for Payer: Kentucky WC Medicaid |
$28,382.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66,994.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60,294.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,510.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,660.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$71,896.00
|
| Rate for Payer: Ohio Health Group HMO |
$61,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,621.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,327.00
|
| Rate for Payer: PHCS Commercial |
$78,432.00
|
| Rate for Payer: United Healthcare All Payer |
$71,896.00
|
| Rate for Payer: Aetna Commercial |
$62,909.00
|
| Rate for Payer: Anthem Medicaid |
$28,096.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63,726.00
|
| Rate for Payer: Cash Price |
$40,850.00
|
| Rate for Payer: Cigna Commercial |
$67,811.00
|
|
|
VISCOAT (CHONDROINTIN SO4- 1EA
|
Facility
|
IP
|
$618.64
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
25003576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.42 |
| Max. Negotiated Rate |
$593.89 |
| Rate for Payer: Aetna Commercial |
$476.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.54
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cigna Commercial |
$513.47
|
| Rate for Payer: First Health Commercial |
$587.71
|
| Rate for Payer: Humana Commercial |
$525.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$507.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$544.40
|
| Rate for Payer: Ohio Health Group HMO |
$463.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.78
|
| Rate for Payer: PHCS Commercial |
$593.89
|
| Rate for Payer: United Healthcare All Payer |
$544.40
|
|
|
VISCOAT (CHONDROINTIN SO4- 1EA
|
Facility
|
OP
|
$618.64
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
25003576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.42 |
| Max. Negotiated Rate |
$593.89 |
| Rate for Payer: Aetna Commercial |
$476.35
|
| Rate for Payer: Anthem Medicaid |
$212.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.54
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cigna Commercial |
$513.47
|
| Rate for Payer: First Health Commercial |
$587.71
|
| Rate for Payer: Humana Commercial |
$525.84
|
| Rate for Payer: Humana KY Medicaid |
$212.75
|
| Rate for Payer: Kentucky WC Medicaid |
$214.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$507.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$544.40
|
| Rate for Payer: Ohio Health Group HMO |
$463.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.78
|
| Rate for Payer: PHCS Commercial |
$593.89
|
| Rate for Payer: United Healthcare All Payer |
$544.40
|
|
|
VISINE(TETRAHYDROZOLINE) 15ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 536121794
|
| Hospital Charge Code |
25001679
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
VISINE(TETRAHYDROZOLINE) 15ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 536121794
|
| Hospital Charge Code |
25001679
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
VISION BLUE
|
Facility
|
OP
|
$349.10
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
25003577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.38 |
| Max. Negotiated Rate |
$335.14 |
| Rate for Payer: Aetna Commercial |
$268.81
|
| Rate for Payer: Anthem Medicaid |
$120.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.30
|
| Rate for Payer: Cash Price |
$174.55
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: First Health Commercial |
$331.64
|
| Rate for Payer: Humana Commercial |
$296.74
|
| Rate for Payer: Humana KY Medicaid |
$120.06
|
| Rate for Payer: Kentucky WC Medicaid |
$121.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.21
|
| Rate for Payer: Ohio Health Group HMO |
$261.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.22
|
| Rate for Payer: PHCS Commercial |
$335.14
|
| Rate for Payer: United Healthcare All Payer |
$307.21
|
|
