|
VODA LEFT 3 7F
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
VODA LEFT 3 7F
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
VOICE PROSTH AUG/ALT COMM
|
Facility
|
IP
|
$334.00
|
|
|
Service Code
|
HCPCS 92597
|
| Hospital Charge Code |
44000008
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$320.64 |
| Rate for Payer: Aetna Commercial |
$257.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$260.52
|
| Rate for Payer: Cash Price |
$167.00
|
| Rate for Payer: Cigna Commercial |
$277.22
|
| Rate for Payer: First Health Commercial |
$317.30
|
| Rate for Payer: Humana Commercial |
$283.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$273.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$246.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$293.92
|
| Rate for Payer: Ohio Health Group HMO |
$250.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.54
|
| Rate for Payer: PHCS Commercial |
$320.64
|
| Rate for Payer: United Healthcare All Payer |
$293.92
|
|
|
VOICE PROSTH AUG/ALT COMM
|
Facility
|
OP
|
$334.00
|
|
|
Service Code
|
HCPCS 92597
|
| Hospital Charge Code |
44000008
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$320.64 |
| Rate for Payer: Aetna Commercial |
$257.18
|
| Rate for Payer: Anthem Medicaid |
$114.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$260.52
|
| Rate for Payer: Cash Price |
$167.00
|
| Rate for Payer: Cigna Commercial |
$277.22
|
| Rate for Payer: First Health Commercial |
$317.30
|
| Rate for Payer: Humana Commercial |
$283.90
|
| Rate for Payer: Humana KY Medicaid |
$114.86
|
| Rate for Payer: Kentucky WC Medicaid |
$116.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$273.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$246.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$293.92
|
| Rate for Payer: Ohio Health Group HMO |
$250.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.54
|
| Rate for Payer: PHCS Commercial |
$320.64
|
| Rate for Payer: United Healthcare All Payer |
$293.92
|
|
|
VOIDING CYSTOGRAM
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
32000147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$63.96 |
| Max. Negotiated Rate |
$472.32 |
| Rate for Payer: Aetna Commercial |
$378.84
|
| Rate for Payer: Anthem Medicaid |
$169.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$408.36
|
| Rate for Payer: First Health Commercial |
$467.40
|
| Rate for Payer: Humana Commercial |
$418.20
|
| Rate for Payer: Humana KY Medicaid |
$169.20
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$170.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.96
|
| Rate for Payer: Ohio Health Group HMO |
$369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.52
|
| Rate for Payer: PHCS Commercial |
$472.32
|
| Rate for Payer: United Healthcare All Payer |
$432.96
|
|
|
VOIDING CYSTOGRAM
|
Professional
|
Both
|
$492.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
32000147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$137.30
|
| Rate for Payer: Anthem Medicaid |
$56.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$492.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$123.23
|
| Rate for Payer: Healthspan PPO |
$128.66
|
| Rate for Payer: Humana Medicaid |
$56.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.00
|
| Rate for Payer: Molina Healthcare Passport |
$56.86
|
| Rate for Payer: Multiplan PHCS |
$295.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$344.40
|
| Rate for Payer: UHCCP Medicaid |
$172.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.43
|
|
|
VOIDING CYSTOGRAM
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
32000147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$63.96 |
| Max. Negotiated Rate |
$472.32 |
| Rate for Payer: Aetna Commercial |
$378.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$408.36
|
| Rate for Payer: First Health Commercial |
$467.40
|
| Rate for Payer: Humana Commercial |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.96
|
| Rate for Payer: Ohio Health Group HMO |
$369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.52
|
| Rate for Payer: PHCS Commercial |
$472.32
|
| Rate for Payer: United Healthcare All Payer |
$432.96
|
|
|
VOIDING CYSTOGRAM(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
320P0147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$137.30 |
| Rate for Payer: Aetna Commercial |
$137.30
|
| Rate for Payer: Anthem Medicaid |
$56.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$123.23
|
| Rate for Payer: Healthspan PPO |
$128.66
|
| Rate for Payer: Humana Medicaid |
$56.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.00
|
| Rate for Payer: Molina Healthcare Passport |
$56.86
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.43
|
|
|
VOIDING CYSTOGRAM(T
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
320T0147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem Medicaid |
$143.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Humana KY Medicaid |
$143.41
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$144.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.27
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
VOIDING CYSTOGRAM(T
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
320T0147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.27
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
VOLTAREN 1% GEL (100GM)
|
Facility
|
IP
|
$0.89
|
|
|
Service Code
|
NDC 67815203
|
| Hospital Charge Code |
25001702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna Commercial |
$0.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna Commercial |
$0.74
|
| Rate for Payer: First Health Commercial |
$0.85
|
| Rate for Payer: Humana Commercial |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.78
|
| Rate for Payer: Ohio Health Group HMO |
$0.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.28
|
| Rate for Payer: PHCS Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Payer |
$0.78
|
|
|
VOLTAREN 1% GEL (100GM)
|
Facility
|
OP
|
$0.89
|
|
|
Service Code
|
NDC 67815203
|
| Hospital Charge Code |
25001702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna Commercial |
$0.69
|
| Rate for Payer: Anthem Medicaid |
$0.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna Commercial |
$0.74
|
| Rate for Payer: First Health Commercial |
$0.85
|
| Rate for Payer: Humana Commercial |
$0.76
|
| Rate for Payer: Humana KY Medicaid |
$0.31
|
| Rate for Payer: Kentucky WC Medicaid |
$0.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.78
|
| Rate for Payer: Ohio Health Group HMO |
$0.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.28
|
| Rate for Payer: PHCS Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Payer |
$0.78
|
|
|
VOLTAREN 1% GEL (50 GM)
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 67815202
|
| Hospital Charge Code |
25004468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.31
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna Commercial |
$1.39
|
| Rate for Payer: First Health Commercial |
$1.60
|
| Rate for Payer: Humana Commercial |
$1.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.48
|
| Rate for Payer: Ohio Health Group HMO |
$1.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Payer |
$1.48
|
|
|
VOLTAREN 1% GEL (50 GM)
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 67815202
|
| Hospital Charge Code |
25004468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Anthem Medicaid |
$0.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.31
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna Commercial |
$1.39
|
| Rate for Payer: First Health Commercial |
$1.60
|
| Rate for Payer: Humana Commercial |
$1.43
|
| Rate for Payer: Humana KY Medicaid |
$0.58
|
| Rate for Payer: Kentucky WC Medicaid |
$0.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.48
|
| Rate for Payer: Ohio Health Group HMO |
$1.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Payer |
$1.48
|
|
|
VOLTAREN (DICLOFENAC) 0. 2.5ML
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
25001701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.33
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna Commercial |
$1.42
|
| Rate for Payer: First Health Commercial |
$1.62
|
| Rate for Payer: Humana Commercial |
$1.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.50
|
| Rate for Payer: Ohio Health Group HMO |
$1.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.53
|
| Rate for Payer: PHCS Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Payer |
$1.50
|
|
|
VOLTAREN (DICLOFENAC) 0. 2.5ML
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
25001701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Anthem Medicaid |
$0.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.33
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna Commercial |
$1.42
|
| Rate for Payer: First Health Commercial |
$1.62
|
| Rate for Payer: Humana Commercial |
$1.45
|
| Rate for Payer: Humana KY Medicaid |
$0.59
|
| Rate for Payer: Kentucky WC Medicaid |
$0.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.50
|
| Rate for Payer: Ohio Health Group HMO |
$1.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.53
|
| Rate for Payer: PHCS Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Payer |
$1.50
|
|
|
VOLTAREN (DICLOFENAC 50MG/1TAB
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 16571020210
|
| Hospital Charge Code |
25001699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
VOLTAREN (DICLOFENAC 50MG/1TAB
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 16571020210
|
| Hospital Charge Code |
25001699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
VOLTAREN (DICLOFENAC 75MG/1TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 68001028100
|
| Hospital Charge Code |
25001700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
VOLTAREN (DICLOFENAC 75MG/1TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 68001028100
|
| Hospital Charge Code |
25001700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
|
|
VOLUME ORAL SUSP 450 ML 1%
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
25003648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$23.14 |
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.80
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cigna Commercial |
$20.00
|
| Rate for Payer: First Health Commercial |
$22.90
|
| Rate for Payer: Humana Commercial |
$20.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.21
|
| Rate for Payer: Ohio Health Group HMO |
$18.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.47
|
| Rate for Payer: PHCS Commercial |
$23.14
|
| Rate for Payer: United Healthcare All Payer |
$21.21
|
|
|
VOLUME ORAL SUSP 450 ML 1%
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
25003648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$23.14 |
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Anthem Medicaid |
$8.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.80
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cigna Commercial |
$20.00
|
| Rate for Payer: First Health Commercial |
$22.90
|
| Rate for Payer: Humana Commercial |
$20.48
|
| Rate for Payer: Humana KY Medicaid |
$8.29
|
| Rate for Payer: Kentucky WC Medicaid |
$8.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.21
|
| Rate for Payer: Ohio Health Group HMO |
$18.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.47
|
| Rate for Payer: PHCS Commercial |
$23.14
|
| Rate for Payer: United Healthcare All Payer |
$21.21
|
|
|
VOSPIRE ER 4MG(ALBUTEROL SULF)
|
Facility
|
OP
|
$9.43
|
|
|
Service Code
|
NDC 378412201
|
| Hospital Charge Code |
25001703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Anthem Medicaid |
$3.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: First Health Commercial |
$8.96
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Humana KY Medicaid |
$3.24
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$9.05
|
| Rate for Payer: United Healthcare All Payer |
$8.30
|
|
|
VOSPIRE ER 4MG(ALBUTEROL SULF)
|
Facility
|
IP
|
$9.43
|
|
|
Service Code
|
NDC 378412201
|
| Hospital Charge Code |
25001703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: First Health Commercial |
$8.96
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$9.05
|
| Rate for Payer: United Healthcare All Payer |
$8.30
|
|
|
VPRIV 100 UNITS (400 UNIT VL)
|
Facility
|
IP
|
$7,961.69
|
|
|
Service Code
|
HCPCS J3385
|
| Hospital Charge Code |
25002420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,035.02 |
| Max. Negotiated Rate |
$7,643.22 |
| Rate for Payer: Aetna Commercial |
$6,130.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,210.12
|
| Rate for Payer: Cash Price |
$3,980.84
|
| Rate for Payer: Cigna Commercial |
$6,608.20
|
| Rate for Payer: First Health Commercial |
$7,563.61
|
| Rate for Payer: Humana Commercial |
$6,767.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,528.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,875.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,388.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,006.29
|
| Rate for Payer: Ohio Health Group HMO |
$5,971.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,592.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,035.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,468.12
|
| Rate for Payer: PHCS Commercial |
$7,643.22
|
| Rate for Payer: United Healthcare All Payer |
$7,006.29
|
|
