|
VERSED 1MG (5MG/ML VL)
|
Facility
|
IP
|
$77.84
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.35 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$59.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.72
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Cigna Commercial |
$64.61
|
| Rate for Payer: First Health Commercial |
$73.95
|
| Rate for Payer: Humana Commercial |
$66.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.50
|
| Rate for Payer: Ohio Health Group HMO |
$58.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.71
|
| Rate for Payer: PHCS Commercial |
$74.73
|
| Rate for Payer: United Healthcare All Payer |
$68.50
|
|
|
VERSED 1MG (5MG/ML VL)
|
Facility
|
OP
|
$77.84
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.35 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$59.94
|
| Rate for Payer: Anthem Medicaid |
$26.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.72
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Cigna Commercial |
$64.61
|
| Rate for Payer: First Health Commercial |
$73.95
|
| Rate for Payer: Humana Commercial |
$66.16
|
| Rate for Payer: Humana KY Medicaid |
$26.77
|
| Rate for Payer: Kentucky WC Medicaid |
$27.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.50
|
| Rate for Payer: Ohio Health Group HMO |
$58.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.71
|
| Rate for Payer: PHCS Commercial |
$74.73
|
| Rate for Payer: United Healthcare All Payer |
$68.50
|
|
|
VERSED (MIDAZOLAM) 5MG/2.5ML
|
Facility
|
OP
|
$10.75
|
|
|
Service Code
|
NDC 54356699
|
| Hospital Charge Code |
25003569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$10.32 |
| Rate for Payer: Aetna Commercial |
$8.28
|
| Rate for Payer: Anthem Medicaid |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna Commercial |
$8.92
|
| Rate for Payer: First Health Commercial |
$10.21
|
| Rate for Payer: Humana Commercial |
$9.14
|
| Rate for Payer: Humana KY Medicaid |
$3.70
|
| Rate for Payer: Kentucky WC Medicaid |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.46
|
| Rate for Payer: Ohio Health Group HMO |
$8.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.42
|
| Rate for Payer: PHCS Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Payer |
$9.46
|
|
|
VERSED (MIDAZOLAM) 5MG/2.5ML
|
Facility
|
IP
|
$10.75
|
|
|
Service Code
|
NDC 54356699
|
| Hospital Charge Code |
25003569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$10.32 |
| Rate for Payer: Aetna Commercial |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna Commercial |
$8.92
|
| Rate for Payer: First Health Commercial |
$10.21
|
| Rate for Payer: Humana Commercial |
$9.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.46
|
| Rate for Payer: Ohio Health Group HMO |
$8.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.42
|
| Rate for Payer: PHCS Commercial |
$10.32
|
| Rate for Payer: United Healthcare All Payer |
$9.46
|
|
|
VERTEBROPLASTY ADDL INJECT
|
Facility
|
OP
|
$7,191.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
76100423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,157.30 |
| Max. Negotiated Rate |
$6,903.36 |
| Rate for Payer: Aetna Commercial |
$5,537.07
|
| Rate for Payer: Anthem Medicaid |
$2,472.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,608.98
|
| Rate for Payer: Cash Price |
$3,595.50
|
| Rate for Payer: Cigna Commercial |
$5,968.53
|
| Rate for Payer: First Health Commercial |
$6,831.45
|
| Rate for Payer: Humana Commercial |
$6,112.35
|
| Rate for Payer: Humana KY Medicaid |
$2,472.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,498.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,896.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,306.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,157.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,522.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,328.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,393.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,752.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,256.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,961.79
|
| Rate for Payer: PHCS Commercial |
$6,903.36
|
| Rate for Payer: United Healthcare All Payer |
$6,328.08
|
|
|
VERTEBROPLASTY ADDL INJECT
|
Facility
|
IP
|
$7,191.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
76100423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,157.30 |
| Max. Negotiated Rate |
$6,903.36 |
| Rate for Payer: Aetna Commercial |
$5,537.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,608.98
|
| Rate for Payer: Cash Price |
$3,595.50
|
| Rate for Payer: Cigna Commercial |
$5,968.53
|
| Rate for Payer: First Health Commercial |
$6,831.45
|
| Rate for Payer: Humana Commercial |
$6,112.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,896.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,306.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,157.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,328.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,393.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,752.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,256.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,961.79
|
| Rate for Payer: PHCS Commercial |
$6,903.36
|
| Rate for Payer: United Healthcare All Payer |
$6,328.08
|
|
|
VERTEBROPLASTY ADDL INJECT
|
Professional
|
Both
|
$7,191.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
76100423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$4,314.60 |
| Rate for Payer: Ambetter Exchange |
$195.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.25
|
| Rate for Payer: Anthem Medicaid |
$734.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$195.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$195.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$235.01
|
| Rate for Payer: Cash Price |
$3,595.50
|
| Rate for Payer: Cash Price |
$3,595.50
|
| Rate for Payer: Cigna Commercial |
$401.45
|
| Rate for Payer: Humana Medicaid |
$734.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$195.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$749.53
|
| Rate for Payer: Molina Healthcare Passport |
$734.83
|
| Rate for Payer: Multiplan PHCS |
$4,314.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$254.59
|
| Rate for Payer: UHCCP Medicaid |
$170.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$742.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$195.84
|
|
|
VERTEBROPLASTY ADDL INJECT(P
|
Professional
|
Both
|
$2,325.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
761P0423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$1,395.00 |
| Rate for Payer: Ambetter Exchange |
$195.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.25
|
| Rate for Payer: Anthem Medicaid |
$734.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$195.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$195.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$235.01
|
| Rate for Payer: Cash Price |
$1,162.50
|
| Rate for Payer: Cash Price |
$1,162.50
|
| Rate for Payer: Cigna Commercial |
$401.45
|
| Rate for Payer: Humana Medicaid |
$734.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$195.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$749.53
|
| Rate for Payer: Molina Healthcare Passport |
$734.83
|
| Rate for Payer: Multiplan PHCS |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$254.59
|
| Rate for Payer: UHCCP Medicaid |
$170.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$742.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$195.84
|
|
|
VERTEBROPLASTY ADDL INJECT(T
|
Facility
|
IP
|
$4,866.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
761T0423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,459.80 |
| Max. Negotiated Rate |
$4,671.36 |
| Rate for Payer: Aetna Commercial |
$3,746.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,795.48
|
| Rate for Payer: Cash Price |
$2,433.00
|
| Rate for Payer: Cigna Commercial |
$4,038.78
|
| Rate for Payer: First Health Commercial |
$4,622.70
|
| Rate for Payer: Humana Commercial |
$4,136.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,990.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,591.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,459.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,282.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,649.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,892.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,233.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,357.54
|
| Rate for Payer: PHCS Commercial |
$4,671.36
|
| Rate for Payer: United Healthcare All Payer |
$4,282.08
|
|
|
VERTEBROPLASTY ADDL INJECT(T
|
Facility
|
OP
|
$4,866.00
|
|
|
Service Code
|
HCPCS 22512
|
| Hospital Charge Code |
761T0423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,459.80 |
| Max. Negotiated Rate |
$4,671.36 |
| Rate for Payer: Aetna Commercial |
$3,746.82
|
| Rate for Payer: Anthem Medicaid |
$1,673.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,795.48
|
| Rate for Payer: Cash Price |
$2,433.00
|
| Rate for Payer: Cigna Commercial |
$4,038.78
|
| Rate for Payer: First Health Commercial |
$4,622.70
|
| Rate for Payer: Humana Commercial |
$4,136.10
|
| Rate for Payer: Humana KY Medicaid |
$1,673.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,690.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,990.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,591.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,459.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,706.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,282.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,649.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,892.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,233.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,357.54
|
| Rate for Payer: PHCS Commercial |
$4,671.36
|
| Rate for Payer: United Healthcare All Payer |
$4,282.08
|
|
|
VESEL MAPING VESS HEMO GRAFT
|
Facility
|
IP
|
$362.00
|
|
|
Service Code
|
HCPCS G0365
|
| Hospital Charge Code |
76102537
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.60 |
| Max. Negotiated Rate |
$347.52 |
| Rate for Payer: Aetna Commercial |
$278.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.36
|
| Rate for Payer: Cash Price |
$181.00
|
| Rate for Payer: Cigna Commercial |
$300.46
|
| Rate for Payer: First Health Commercial |
$343.90
|
| Rate for Payer: Humana Commercial |
$307.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$296.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$318.56
|
| Rate for Payer: Ohio Health Group HMO |
$271.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$289.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$249.78
|
| Rate for Payer: PHCS Commercial |
$347.52
|
| Rate for Payer: United Healthcare All Payer |
$318.56
|
|
|
VESEL MAPING VESS HEMO GRAFT
|
Facility
|
OP
|
$362.00
|
|
|
Service Code
|
HCPCS G0365
|
| Hospital Charge Code |
76102537
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.60 |
| Max. Negotiated Rate |
$347.52 |
| Rate for Payer: Aetna Commercial |
$278.74
|
| Rate for Payer: Anthem Medicaid |
$124.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.36
|
| Rate for Payer: Cash Price |
$181.00
|
| Rate for Payer: Cigna Commercial |
$300.46
|
| Rate for Payer: First Health Commercial |
$343.90
|
| Rate for Payer: Humana Commercial |
$307.70
|
| Rate for Payer: Humana KY Medicaid |
$124.49
|
| Rate for Payer: Kentucky WC Medicaid |
$125.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$296.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$126.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$318.56
|
| Rate for Payer: Ohio Health Group HMO |
$271.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$289.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$249.78
|
| Rate for Payer: PHCS Commercial |
$347.52
|
| Rate for Payer: United Healthcare All Payer |
$318.56
|
|
|
VESICARE 5 MG TAB
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 67877052790
|
| Hospital Charge Code |
25001663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
VESICARE 5 MG TAB
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 67877052790
|
| Hospital Charge Code |
25001663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
VESSEL INJECTION PROCEDURE
|
Facility
|
OP
|
$1,822.00
|
|
|
Service Code
|
HCPCS 36299
|
| Hospital Charge Code |
76102577
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$546.60 |
| Max. Negotiated Rate |
$1,749.12 |
| Rate for Payer: Aetna Commercial |
$1,402.94
|
| Rate for Payer: Anthem Medicaid |
$626.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,421.16
|
| Rate for Payer: Cash Price |
$911.00
|
| Rate for Payer: Cigna Commercial |
$1,512.26
|
| Rate for Payer: First Health Commercial |
$1,730.90
|
| Rate for Payer: Humana Commercial |
$1,548.70
|
| Rate for Payer: Humana KY Medicaid |
$626.59
|
| Rate for Payer: Kentucky WC Medicaid |
$632.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,494.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$639.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,603.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,366.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,457.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,585.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,257.18
|
| Rate for Payer: PHCS Commercial |
$1,749.12
|
| Rate for Payer: United Healthcare All Payer |
$1,603.36
|
|
|
VESSEL INJECTION PROCEDURE
|
Facility
|
IP
|
$1,822.00
|
|
|
Service Code
|
HCPCS 36299
|
| Hospital Charge Code |
761T2577
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$546.60 |
| Max. Negotiated Rate |
$1,749.12 |
| Rate for Payer: Aetna Commercial |
$1,402.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,421.16
|
| Rate for Payer: Cash Price |
$911.00
|
| Rate for Payer: Cigna Commercial |
$1,512.26
|
| Rate for Payer: First Health Commercial |
$1,730.90
|
| Rate for Payer: Humana Commercial |
$1,548.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,494.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,603.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,366.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,457.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,585.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,257.18
|
| Rate for Payer: PHCS Commercial |
$1,749.12
|
| Rate for Payer: United Healthcare All Payer |
$1,603.36
|
|
|
VESSEL INJECTION PROCEDURE
|
Professional
|
Both
|
$1,960.00
|
|
|
Service Code
|
HCPCS 36299
|
| Hospital Charge Code |
76102577
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,372.00 |
| Rate for Payer: Cash Price |
$980.00
|
| Rate for Payer: Cash Price |
$980.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,176.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,372.00
|
| Rate for Payer: UHCCP Medicaid |
$686.00
|
|
|
VESSEL INJECTION PROCEDURE
|
Facility
|
OP
|
$1,822.00
|
|
|
Service Code
|
HCPCS 36299
|
| Hospital Charge Code |
761T2577
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$546.60 |
| Max. Negotiated Rate |
$1,749.12 |
| Rate for Payer: Aetna Commercial |
$1,402.94
|
| Rate for Payer: Anthem Medicaid |
$626.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,421.16
|
| Rate for Payer: Cash Price |
$911.00
|
| Rate for Payer: Cigna Commercial |
$1,512.26
|
| Rate for Payer: First Health Commercial |
$1,730.90
|
| Rate for Payer: Humana Commercial |
$1,548.70
|
| Rate for Payer: Humana KY Medicaid |
$626.59
|
| Rate for Payer: Kentucky WC Medicaid |
$632.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,494.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$639.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,603.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,366.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,457.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,585.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,257.18
|
| Rate for Payer: PHCS Commercial |
$1,749.12
|
| Rate for Payer: United Healthcare All Payer |
$1,603.36
|
|
|
VESSEL INJECTION PROCEDURE
|
Facility
|
IP
|
$1,822.00
|
|
|
Service Code
|
HCPCS 36299
|
| Hospital Charge Code |
76102577
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$546.60 |
| Max. Negotiated Rate |
$1,749.12 |
| Rate for Payer: Aetna Commercial |
$1,402.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,421.16
|
| Rate for Payer: Cash Price |
$911.00
|
| Rate for Payer: Cigna Commercial |
$1,512.26
|
| Rate for Payer: First Health Commercial |
$1,730.90
|
| Rate for Payer: Humana Commercial |
$1,548.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,494.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,603.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,366.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,457.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,585.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,257.18
|
| Rate for Payer: PHCS Commercial |
$1,749.12
|
| Rate for Payer: United Healthcare All Payer |
$1,603.36
|
|
|
VFEND I.V. 10MG (200MG VIAL)
|
Facility
|
OP
|
$329.30
|
|
|
Service Code
|
HCPCS J3465
|
| Hospital Charge Code |
25002431
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.79 |
| Max. Negotiated Rate |
$316.13 |
| Rate for Payer: Aetna Commercial |
$253.56
|
| Rate for Payer: Anthem Medicaid |
$113.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.85
|
| Rate for Payer: Cash Price |
$164.65
|
| Rate for Payer: Cigna Commercial |
$273.32
|
| Rate for Payer: First Health Commercial |
$312.83
|
| Rate for Payer: Humana Commercial |
$279.90
|
| Rate for Payer: Humana KY Medicaid |
$113.25
|
| Rate for Payer: Kentucky WC Medicaid |
$114.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.78
|
| Rate for Payer: Ohio Health Group HMO |
$246.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.22
|
| Rate for Payer: PHCS Commercial |
$316.13
|
| Rate for Payer: United Healthcare All Payer |
$289.78
|
|
|
VFEND I.V. 10MG (200MG VIAL)
|
Facility
|
IP
|
$329.30
|
|
|
Service Code
|
HCPCS J3465
|
| Hospital Charge Code |
25002431
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.79 |
| Max. Negotiated Rate |
$316.13 |
| Rate for Payer: Aetna Commercial |
$253.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.85
|
| Rate for Payer: Cash Price |
$164.65
|
| Rate for Payer: Cigna Commercial |
$273.32
|
| Rate for Payer: First Health Commercial |
$312.83
|
| Rate for Payer: Humana Commercial |
$279.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.78
|
| Rate for Payer: Ohio Health Group HMO |
$246.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.22
|
| Rate for Payer: PHCS Commercial |
$316.13
|
| Rate for Payer: United Healthcare All Payer |
$289.78
|
|
|
VFEND(VORICONAZOLE)200MG TAB
|
Facility
|
IP
|
$24.50
|
|
|
Service Code
|
NDC 68462057330
|
| Hospital Charge Code |
25001665
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$23.52 |
| Rate for Payer: Aetna Commercial |
$18.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.11
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Cigna Commercial |
$20.34
|
| Rate for Payer: First Health Commercial |
$23.27
|
| Rate for Payer: Humana Commercial |
$20.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.56
|
| Rate for Payer: Ohio Health Group HMO |
$18.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.91
|
| Rate for Payer: PHCS Commercial |
$23.52
|
| Rate for Payer: United Healthcare All Payer |
$21.56
|
|
|
VFEND(VORICONAZOLE)200MG TAB
|
Facility
|
OP
|
$24.50
|
|
|
Service Code
|
NDC 68462057330
|
| Hospital Charge Code |
25001665
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$23.52 |
| Rate for Payer: Aetna Commercial |
$18.86
|
| Rate for Payer: Anthem Medicaid |
$8.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.11
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Cigna Commercial |
$20.34
|
| Rate for Payer: First Health Commercial |
$23.27
|
| Rate for Payer: Humana Commercial |
$20.82
|
| Rate for Payer: Humana KY Medicaid |
$8.43
|
| Rate for Payer: Kentucky WC Medicaid |
$8.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.56
|
| Rate for Payer: Ohio Health Group HMO |
$18.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.91
|
| Rate for Payer: PHCS Commercial |
$23.52
|
| Rate for Payer: United Healthcare All Payer |
$21.56
|
|
|
VFEND (VORICONAZOLE) 50MG TAB
|
Facility
|
OP
|
$9.49
|
|
|
Service Code
|
NDC 49317030
|
| Hospital Charge Code |
25001664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna Commercial |
$7.31
|
| Rate for Payer: Anthem Medicaid |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Humana KY Medicaid |
$3.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.35
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.11
|
| Rate for Payer: United Healthcare All Payer |
$8.35
|
|
|
VFEND (VORICONAZOLE) 50MG TAB
|
Facility
|
IP
|
$9.49
|
|
|
Service Code
|
NDC 49317030
|
| Hospital Charge Code |
25001664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna Commercial |
$7.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.35
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.11
|
| Rate for Payer: United Healthcare All Payer |
$8.35
|
|
