|
VISTARIL(HYDROXYZINE 25MG/1CAP
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 185067401
|
| Hospital Charge Code |
25001681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
VISTARIL(HYDROXYZINE 25MG/1CAP
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 185067401
|
| Hospital Charge Code |
25001681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
VISTARIL(HYDROXYZINE 50MG/1CAP
|
Facility
|
IP
|
$4.63
|
|
|
Service Code
|
NDC 60687070701
|
| Hospital Charge Code |
25001682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
VISTARIL(HYDROXYZINE 50MG/1CAP
|
Facility
|
OP
|
$4.63
|
|
|
Service Code
|
NDC 60687070701
|
| Hospital Charge Code |
25001682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
OP
|
$18.92
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Aetna Commercial |
$14.57
|
| Rate for Payer: Anthem Medicaid |
$6.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Cigna Commercial |
$15.70
|
| Rate for Payer: First Health Commercial |
$17.97
|
| Rate for Payer: Humana Commercial |
$16.08
|
| Rate for Payer: Humana KY Medicaid |
$6.51
|
| Rate for Payer: Kentucky WC Medicaid |
$6.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.65
|
| Rate for Payer: Ohio Health Group HMO |
$14.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.87
|
| Rate for Payer: PHCS Commercial |
$18.16
|
| Rate for Payer: United Healthcare All Payer |
$16.65
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Professional
|
Both
|
$18.92
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$18.92 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.92
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Healthspan PPO |
$0.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.84
|
| Rate for Payer: Multiplan PHCS |
$11.35
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$13.24
|
| Rate for Payer: UHCCP Medicaid |
$6.62
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
IP
|
$18.92
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Aetna Commercial |
$14.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Cigna Commercial |
$15.70
|
| Rate for Payer: First Health Commercial |
$17.97
|
| Rate for Payer: Humana Commercial |
$16.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.65
|
| Rate for Payer: Ohio Health Group HMO |
$14.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.87
|
| Rate for Payer: PHCS Commercial |
$18.16
|
| Rate for Payer: United Healthcare All Payer |
$16.65
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
IP
|
$18.92
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Aetna Commercial |
$14.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Cigna Commercial |
$15.70
|
| Rate for Payer: First Health Commercial |
$17.97
|
| Rate for Payer: Humana Commercial |
$16.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.65
|
| Rate for Payer: Ohio Health Group HMO |
$14.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.87
|
| Rate for Payer: PHCS Commercial |
$18.16
|
| Rate for Payer: United Healthcare All Payer |
$16.65
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
OP
|
$18.92
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Aetna Commercial |
$14.57
|
| Rate for Payer: Anthem Medicaid |
$6.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Cash Price |
$9.46
|
| Rate for Payer: Cigna Commercial |
$15.70
|
| Rate for Payer: First Health Commercial |
$17.97
|
| Rate for Payer: Humana Commercial |
$16.08
|
| Rate for Payer: Humana KY Medicaid |
$6.51
|
| Rate for Payer: Kentucky WC Medicaid |
$6.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.65
|
| Rate for Payer: Ohio Health Group HMO |
$14.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.87
|
| Rate for Payer: PHCS Commercial |
$18.16
|
| Rate for Payer: United Healthcare All Payer |
$16.65
|
|
|
VISTARIL UP TO 25MG (50MG/ML)
|
Facility
|
IP
|
$72.61
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$69.71 |
| Rate for Payer: Aetna Commercial |
$55.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.64
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$60.27
|
| Rate for Payer: First Health Commercial |
$68.98
|
| Rate for Payer: Humana Commercial |
$61.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.90
|
| Rate for Payer: Ohio Health Group HMO |
$54.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.51
|
| Rate for Payer: PHCS Commercial |
$69.71
|
| Rate for Payer: United Healthcare All Payer |
$63.90
|
|
|
VISTARIL UP TO 25MG (50MG/ML)
|
Facility
|
OP
|
$72.61
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$69.71 |
| Rate for Payer: Aetna Commercial |
$55.91
|
| Rate for Payer: Anthem Medicaid |
$24.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.64
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$60.27
|
| Rate for Payer: First Health Commercial |
$68.98
|
| Rate for Payer: Humana Commercial |
$61.72
|
| Rate for Payer: Humana KY Medicaid |
$24.97
|
| Rate for Payer: Kentucky WC Medicaid |
$25.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.90
|
| Rate for Payer: Ohio Health Group HMO |
$54.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.51
|
| Rate for Payer: PHCS Commercial |
$69.71
|
| Rate for Payer: United Healthcare All Payer |
$63.90
|
|
|
VISTARIL UP TO 25MG (50MG/ML)
|
Professional
|
Both
|
$72.61
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$72.61 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.61
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Healthspan PPO |
$0.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.84
|
| Rate for Payer: Multiplan PHCS |
$43.57
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.83
|
| Rate for Payer: UHCCP Medicaid |
$25.41
|
|
|
VISTARIL UP TO 25MG (50MG/ML)
|
Facility
|
OP
|
$72.61
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$69.71 |
| Rate for Payer: Aetna Commercial |
$55.91
|
| Rate for Payer: Anthem Medicaid |
$24.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.64
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$60.27
|
| Rate for Payer: First Health Commercial |
$68.98
|
| Rate for Payer: Humana Commercial |
$61.72
|
| Rate for Payer: Humana KY Medicaid |
$24.97
|
| Rate for Payer: Kentucky WC Medicaid |
$25.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.90
|
| Rate for Payer: Ohio Health Group HMO |
$54.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.51
|
| Rate for Payer: PHCS Commercial |
$69.71
|
| Rate for Payer: United Healthcare All Payer |
$63.90
|
|
|
VISTARIL UP TO 25MG (50MG/ML)
|
Facility
|
IP
|
$72.61
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$69.71 |
| Rate for Payer: Aetna Commercial |
$55.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56.64
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$60.27
|
| Rate for Payer: First Health Commercial |
$68.98
|
| Rate for Payer: Humana Commercial |
$61.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.90
|
| Rate for Payer: Ohio Health Group HMO |
$54.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.51
|
| Rate for Payer: PHCS Commercial |
$69.71
|
| Rate for Payer: United Healthcare All Payer |
$63.90
|
|
|
VISTASEAL FIBRIN SEAL 2ML SYR
|
Facility
|
OP
|
$290.55
|
|
|
Service Code
|
NDC 61953001101
|
| Hospital Charge Code |
25003987
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.77 |
| Max. Negotiated Rate |
$278.93 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Anthem Medicaid |
$99.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.63
|
| Rate for Payer: Cash Price |
$145.28
|
| Rate for Payer: Cigna Commercial |
$241.16
|
| Rate for Payer: First Health Commercial |
$276.02
|
| Rate for Payer: Humana Commercial |
$246.97
|
| Rate for Payer: Humana KY Medicaid |
$99.92
|
| Rate for Payer: Kentucky WC Medicaid |
$100.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$101.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$255.68
|
| Rate for Payer: Ohio Health Group HMO |
$217.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.07
|
| Rate for Payer: PHCS Commercial |
$278.93
|
| Rate for Payer: United Healthcare All Payer |
$255.68
|
|
|
VISTASEAL FIBRIN SEAL 2ML SYR
|
Facility
|
IP
|
$290.55
|
|
|
Service Code
|
NDC 61953001101
|
| Hospital Charge Code |
25003987
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.77 |
| Max. Negotiated Rate |
$278.93 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.63
|
| Rate for Payer: Cash Price |
$145.28
|
| Rate for Payer: Cigna Commercial |
$241.16
|
| Rate for Payer: First Health Commercial |
$276.02
|
| Rate for Payer: Humana Commercial |
$246.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$255.68
|
| Rate for Payer: Ohio Health Group HMO |
$217.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.07
|
| Rate for Payer: PHCS Commercial |
$278.93
|
| Rate for Payer: United Healthcare All Payer |
$255.68
|
|
|
VISTASEAL FIBRIN SEAL 4ML SYR
|
Facility
|
OP
|
$393.24
|
|
|
Service Code
|
NDC 61953001201
|
| Hospital Charge Code |
25003988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.12 |
| Max. Negotiated Rate |
$377.51 |
| Rate for Payer: Aetna Commercial |
$302.79
|
| Rate for Payer: Anthem Medicaid |
$135.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$306.73
|
| Rate for Payer: Cash Price |
$196.62
|
| Rate for Payer: Cigna Commercial |
$326.39
|
| Rate for Payer: First Health Commercial |
$373.58
|
| Rate for Payer: Humana Commercial |
$334.25
|
| Rate for Payer: Humana KY Medicaid |
$135.24
|
| Rate for Payer: Kentucky WC Medicaid |
$136.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$322.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$137.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.05
|
| Rate for Payer: Ohio Health Group HMO |
$294.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.90
|
| Rate for Payer: PHCS Commercial |
$377.51
|
| Rate for Payer: United Healthcare All Payer |
$346.05
|
|
|
VISTASEAL FIBRIN SEAL 4ML SYR
|
Facility
|
IP
|
$393.24
|
|
|
Service Code
|
NDC 61953001201
|
| Hospital Charge Code |
25003988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.12 |
| Max. Negotiated Rate |
$377.51 |
| Rate for Payer: Aetna Commercial |
$302.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$306.73
|
| Rate for Payer: Cash Price |
$196.62
|
| Rate for Payer: Cigna Commercial |
$326.39
|
| Rate for Payer: First Health Commercial |
$373.58
|
| Rate for Payer: Humana Commercial |
$334.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$322.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.05
|
| Rate for Payer: Ohio Health Group HMO |
$294.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.90
|
| Rate for Payer: PHCS Commercial |
$377.51
|
| Rate for Payer: United Healthcare All Payer |
$346.05
|
|
|
VISTASEAL FIBRIN SEALANT 10 ML
|
Facility
|
OP
|
$702.30
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.30 |
| Max. Negotiated Rate |
$674.21 |
| Rate for Payer: Aetna Commercial |
$540.77
|
| Rate for Payer: Anthem Medicaid |
$241.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$547.79
|
| Rate for Payer: Cash Price |
$351.15
|
| Rate for Payer: Cigna Commercial |
$582.91
|
| Rate for Payer: First Health Commercial |
$667.18
|
| Rate for Payer: Humana Commercial |
$596.96
|
| Rate for Payer: Humana KY Medicaid |
$241.52
|
| Rate for Payer: Kentucky WC Medicaid |
$243.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$575.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$518.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$246.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$618.02
|
| Rate for Payer: Ohio Health Group HMO |
$526.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.71
|
| Rate for Payer: PHCS Commercial |
$674.21
|
| Rate for Payer: United Healthcare All Payer |
$618.02
|
|
|
VISTASEAL FIBRIN SEALANT 10 ML
|
Facility
|
IP
|
$702.30
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.30 |
| Max. Negotiated Rate |
$674.21 |
| Rate for Payer: Aetna Commercial |
$540.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$547.79
|
| Rate for Payer: Cash Price |
$351.15
|
| Rate for Payer: Cigna Commercial |
$582.91
|
| Rate for Payer: First Health Commercial |
$667.18
|
| Rate for Payer: Humana Commercial |
$596.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$575.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$518.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$618.02
|
| Rate for Payer: Ohio Health Group HMO |
$526.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.71
|
| Rate for Payer: PHCS Commercial |
$674.21
|
| Rate for Payer: United Healthcare All Payer |
$618.02
|
|
|
VISTIDE(CIDOFOVIR)375MG/ML VL
|
Facility
|
IP
|
$4,033.00
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
25001962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.29 |
| Max. Negotiated Rate |
$3,871.68 |
| Rate for Payer: Aetna Commercial |
$3,105.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,145.74
|
| Rate for Payer: Cash Price |
$2,016.50
|
| Rate for Payer: Cigna Commercial |
$3,347.39
|
| Rate for Payer: First Health Commercial |
$3,831.35
|
| Rate for Payer: Humana Commercial |
$3,428.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,307.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,976.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,209.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,549.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,024.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$806.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$524.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,250.23
|
| Rate for Payer: PHCS Commercial |
$3,871.68
|
| Rate for Payer: United Healthcare All Payer |
$3,549.04
|
|
|
VISTIDE(CIDOFOVIR)375MG/ML VL
|
Facility
|
OP
|
$4,033.00
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
25001962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.29 |
| Max. Negotiated Rate |
$3,871.68 |
| Rate for Payer: Aetna Commercial |
$3,105.41
|
| Rate for Payer: Anthem Medicaid |
$1,386.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$554.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,145.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$775.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$748.16
|
| Rate for Payer: Cash Price |
$2,016.50
|
| Rate for Payer: Cash Price |
$2,016.50
|
| Rate for Payer: Cigna Commercial |
$3,347.39
|
| Rate for Payer: First Health Commercial |
$3,831.35
|
| Rate for Payer: Humana Commercial |
$3,428.05
|
| Rate for Payer: Humana KY Medicaid |
$1,386.95
|
| Rate for Payer: Humana Medicare Advantage |
$554.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,401.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,307.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,976.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$665.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,414.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,549.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,024.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$806.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$524.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,250.23
|
| Rate for Payer: PHCS Commercial |
$3,871.68
|
| Rate for Payer: United Healthcare All Payer |
$3,549.04
|
|
|
VISUAL ACUITY SCREEN
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
51000059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$68.16 |
| Rate for Payer: Aetna Commercial |
$54.67
|
| Rate for Payer: Anthem Medicaid |
$24.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.38
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cigna Commercial |
$58.93
|
| Rate for Payer: First Health Commercial |
$67.45
|
| Rate for Payer: Humana Commercial |
$60.35
|
| Rate for Payer: Humana KY Medicaid |
$24.42
|
| Rate for Payer: Kentucky WC Medicaid |
$24.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.48
|
| Rate for Payer: Ohio Health Group HMO |
$53.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.01
|
| Rate for Payer: PHCS Commercial |
$68.16
|
| Rate for Payer: United Healthcare All Payer |
$62.48
|
|
|
VISUAL ACUITY SCREEN
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
51000059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$68.16 |
| Rate for Payer: Aetna Commercial |
$54.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.38
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cigna Commercial |
$58.93
|
| Rate for Payer: First Health Commercial |
$67.45
|
| Rate for Payer: Humana Commercial |
$60.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.48
|
| Rate for Payer: Ohio Health Group HMO |
$53.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.01
|
| Rate for Payer: PHCS Commercial |
$68.16
|
| Rate for Payer: United Healthcare All Payer |
$62.48
|
|
|
VISUAL ACUITY SCREEN
|
Professional
|
Both
|
$71.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
51000059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$71.00 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$45.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$71.00
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: Healthspan PPO |
$3.45
|
| Rate for Payer: Humana Medicaid |
$45.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.90
|
| Rate for Payer: Molina Healthcare Passport |
$45.00
|
| Rate for Payer: Multiplan PHCS |
$42.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.70
|
| Rate for Payer: UHCCP Medicaid |
$24.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.45
|
|
