|
VIBRAMYCIN(DOXYCYCL 100MG/1TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 53489012005
|
| Hospital Charge Code |
25001666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
VICI STENT 12*120*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 12*120*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 12*90*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 12*90*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 14*120*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 14*120*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 14*60*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 14*60*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 14*90*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 14*90*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 16*120*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 16*120*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 16*60*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 16*60*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 16*90*100
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VICI STENT 16*90*100
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
VIDAZA 100MG/4ML VIAL
|
Facility
|
IP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25003907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$956.87 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,551.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,774.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,200.80
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIDAZA 100MG/4ML VIAL
|
Facility
|
OP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25003907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$956.87 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem Medicaid |
$1,096.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Humana KY Medicaid |
$1,096.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,108.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,118.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,551.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,774.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,200.80
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIDAZA 1 MG/100MG VIAL
|
Facility
|
IP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25002560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$956.87 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,551.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,774.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,200.80
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIDAZA 1 MG/100MG VIAL
|
Facility
|
OP
|
$3,189.56
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
25002560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$956.87 |
| Max. Negotiated Rate |
$3,061.98 |
| Rate for Payer: Aetna Commercial |
$2,455.96
|
| Rate for Payer: Anthem Medicaid |
$1,096.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.86
|
| Rate for Payer: Cash Price |
$1,594.78
|
| Rate for Payer: Cigna Commercial |
$2,647.33
|
| Rate for Payer: First Health Commercial |
$3,030.08
|
| Rate for Payer: Humana Commercial |
$2,711.13
|
| Rate for Payer: Humana KY Medicaid |
$1,096.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,108.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,615.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,118.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.81
|
| Rate for Payer: Ohio Health Group HMO |
$2,392.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,551.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,774.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,200.80
|
| Rate for Payer: PHCS Commercial |
$3,061.98
|
| Rate for Payer: United Healthcare All Payer |
$2,806.81
|
|
|
VIGAMOX 0.5%(MOXIFOX HCL) SOL
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 68180042201
|
| Hospital Charge Code |
25003575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Anthem Medicaid |
$0.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.17
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna Commercial |
$1.25
|
| Rate for Payer: First Health Commercial |
$1.43
|
| Rate for Payer: Humana Commercial |
$1.27
|
| Rate for Payer: Humana KY Medicaid |
$0.52
|
| Rate for Payer: Kentucky WC Medicaid |
$0.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.32
|
| Rate for Payer: Ohio Health Group HMO |
$1.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.03
|
| Rate for Payer: PHCS Commercial |
$1.44
|
| Rate for Payer: United Healthcare All Payer |
$1.32
|
|
|
VIGAMOX 0.5%(MOXIFOX HCL) SOL
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 68180042201
|
| Hospital Charge Code |
25003575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.17
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna Commercial |
$1.25
|
| Rate for Payer: First Health Commercial |
$1.43
|
| Rate for Payer: Humana Commercial |
$1.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.32
|
| Rate for Payer: Ohio Health Group HMO |
$1.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.03
|
| Rate for Payer: PHCS Commercial |
$1.44
|
| Rate for Payer: United Healthcare All Payer |
$1.32
|
|
|
VIGILANT X4 CRT-D
|
Facility
|
IP
|
$85,379.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$25,613.70 |
| Max. Negotiated Rate |
$81,963.84 |
| Rate for Payer: Aetna Commercial |
$65,741.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66,595.62
|
| Rate for Payer: Cash Price |
$42,689.50
|
| Rate for Payer: Cigna Commercial |
$70,864.57
|
| Rate for Payer: First Health Commercial |
$81,110.05
|
| Rate for Payer: Humana Commercial |
$72,572.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70,010.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63,009.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,613.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$75,133.52
|
| Rate for Payer: Ohio Health Group HMO |
$64,034.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68,303.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74,279.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,911.51
|
| Rate for Payer: PHCS Commercial |
$81,963.84
|
| Rate for Payer: United Healthcare All Payer |
$75,133.52
|
|
|
VIGILANT X4 CRT-D
|
Facility
|
OP
|
$85,379.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$25,613.70 |
| Max. Negotiated Rate |
$81,963.84 |
| Rate for Payer: Aetna Commercial |
$65,741.83
|
| Rate for Payer: Anthem Medicaid |
$29,361.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66,595.62
|
| Rate for Payer: Cash Price |
$42,689.50
|
| Rate for Payer: Cigna Commercial |
$70,864.57
|
| Rate for Payer: First Health Commercial |
$81,110.05
|
| Rate for Payer: Humana Commercial |
$72,572.15
|
| Rate for Payer: Humana KY Medicaid |
$29,361.84
|
| Rate for Payer: Kentucky WC Medicaid |
$29,660.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70,010.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63,009.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,613.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,950.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$75,133.52
|
| Rate for Payer: Ohio Health Group HMO |
$64,034.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68,303.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74,279.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,911.51
|
| Rate for Payer: PHCS Commercial |
$81,963.84
|
| Rate for Payer: United Healthcare All Payer |
$75,133.52
|
|
