|
VIPERWIRE .017 335CM
|
Facility
|
OP
|
$1,946.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$583.80 |
| Max. Negotiated Rate |
$1,868.16 |
| Rate for Payer: Aetna Commercial |
$1,498.42
|
| Rate for Payer: Anthem Medicaid |
$669.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.88
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cigna Commercial |
$1,615.18
|
| Rate for Payer: First Health Commercial |
$1,848.70
|
| Rate for Payer: Humana Commercial |
$1,654.10
|
| Rate for Payer: Humana KY Medicaid |
$669.23
|
| Rate for Payer: Kentucky WC Medicaid |
$676.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,595.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,436.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$682.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,712.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,459.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,556.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,693.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,342.74
|
| Rate for Payer: PHCS Commercial |
$1,868.16
|
| Rate for Payer: United Healthcare All Payer |
$1,712.48
|
|
|
VIPERWIRE FLX GEN 2 .018*335CM
|
Facility
|
IP
|
$2,022.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$606.60 |
| Max. Negotiated Rate |
$1,941.12 |
| Rate for Payer: Aetna Commercial |
$1,556.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,577.16
|
| Rate for Payer: Cash Price |
$1,011.00
|
| Rate for Payer: Cigna Commercial |
$1,678.26
|
| Rate for Payer: First Health Commercial |
$1,920.90
|
| Rate for Payer: Humana Commercial |
$1,718.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,658.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,492.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$606.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,779.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,516.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,617.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,759.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,395.18
|
| Rate for Payer: PHCS Commercial |
$1,941.12
|
| Rate for Payer: United Healthcare All Payer |
$1,779.36
|
|
|
VIPERWIRE FLX GEN 2 .018*335CM
|
Facility
|
OP
|
$2,022.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$606.60 |
| Max. Negotiated Rate |
$1,941.12 |
| Rate for Payer: Aetna Commercial |
$1,556.94
|
| Rate for Payer: Anthem Medicaid |
$695.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,577.16
|
| Rate for Payer: Cash Price |
$1,011.00
|
| Rate for Payer: Cigna Commercial |
$1,678.26
|
| Rate for Payer: First Health Commercial |
$1,920.90
|
| Rate for Payer: Humana Commercial |
$1,718.70
|
| Rate for Payer: Humana KY Medicaid |
$695.37
|
| Rate for Payer: Kentucky WC Medicaid |
$702.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,658.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,492.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$606.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$709.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,779.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,516.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,617.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,759.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,395.18
|
| Rate for Payer: PHCS Commercial |
$1,941.12
|
| Rate for Payer: United Healthcare All Payer |
$1,779.36
|
|
|
VIREAD 150 MG TABLET
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 61958040401
|
| Hospital Charge Code |
25001673
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Humana KY Medicaid |
$26.38
|
| Rate for Payer: Kentucky WC Medicaid |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.94
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 150 MG TABLET
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 61958040401
|
| Hospital Charge Code |
25001673
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.94
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 200 MG TABLET
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 61958040501
|
| Hospital Charge Code |
25001674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.94
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 200 MG TABLET
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 61958040501
|
| Hospital Charge Code |
25001674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Humana KY Medicaid |
$26.38
|
| Rate for Payer: Kentucky WC Medicaid |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.94
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 250 MG TABLET
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 61958040601
|
| Hospital Charge Code |
25001675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.94
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 250 MG TABLET
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 61958040601
|
| Hospital Charge Code |
25001675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$73.65 |
| Rate for Payer: Aetna Commercial |
$59.07
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.84
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Cigna Commercial |
$63.68
|
| Rate for Payer: First Health Commercial |
$72.88
|
| Rate for Payer: Humana Commercial |
$65.21
|
| Rate for Payer: Humana KY Medicaid |
$26.38
|
| Rate for Payer: Kentucky WC Medicaid |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.51
|
| Rate for Payer: Ohio Health Group HMO |
$57.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.94
|
| Rate for Payer: PHCS Commercial |
$73.65
|
| Rate for Payer: United Healthcare All Payer |
$67.51
|
|
|
VIREAD 300MG TABLET
|
Facility
|
IP
|
$79.78
|
|
|
Service Code
|
NDC 61958040101
|
| Hospital Charge Code |
25001676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.93 |
| Max. Negotiated Rate |
$76.59 |
| Rate for Payer: Aetna Commercial |
$61.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.23
|
| Rate for Payer: Cash Price |
$39.89
|
| Rate for Payer: Cigna Commercial |
$66.22
|
| Rate for Payer: First Health Commercial |
$75.79
|
| Rate for Payer: Humana Commercial |
$67.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.21
|
| Rate for Payer: Ohio Health Group HMO |
$59.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.05
|
| Rate for Payer: PHCS Commercial |
$76.59
|
| Rate for Payer: United Healthcare All Payer |
$70.21
|
|
|
VIREAD 300MG TABLET
|
Facility
|
OP
|
$79.78
|
|
|
Service Code
|
NDC 61958040101
|
| Hospital Charge Code |
25001676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.93 |
| Max. Negotiated Rate |
$76.59 |
| Rate for Payer: Aetna Commercial |
$61.43
|
| Rate for Payer: Anthem Medicaid |
$27.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.23
|
| Rate for Payer: Cash Price |
$39.89
|
| Rate for Payer: Cigna Commercial |
$66.22
|
| Rate for Payer: First Health Commercial |
$75.79
|
| Rate for Payer: Humana Commercial |
$67.81
|
| Rate for Payer: Humana KY Medicaid |
$27.44
|
| Rate for Payer: Kentucky WC Medicaid |
$27.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.21
|
| Rate for Payer: Ohio Health Group HMO |
$59.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.05
|
| Rate for Payer: PHCS Commercial |
$76.59
|
| Rate for Payer: United Healthcare All Payer |
$70.21
|
|
|
VIROPTIC 1% EYE DROPS
|
Facility
|
IP
|
$4.09
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
25001677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna Commercial |
$3.39
|
| Rate for Payer: First Health Commercial |
$3.89
|
| Rate for Payer: Humana Commercial |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.60
|
| Rate for Payer: Ohio Health Group HMO |
$3.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$3.93
|
| Rate for Payer: United Healthcare All Payer |
$3.60
|
|
|
VIROPTIC 1% EYE DROPS
|
Facility
|
OP
|
$4.09
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
25001677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Anthem Medicaid |
$1.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna Commercial |
$3.39
|
| Rate for Payer: First Health Commercial |
$3.89
|
| Rate for Payer: Humana Commercial |
$3.48
|
| Rate for Payer: Humana KY Medicaid |
$1.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.60
|
| Rate for Payer: Ohio Health Group HMO |
$3.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$3.93
|
| Rate for Payer: United Healthcare All Payer |
$3.60
|
|
|
VIRTUOSO II DR D274DRG
|
Facility
|
OP
|
$84,600.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$25,380.00 |
| Max. Negotiated Rate |
$81,216.00 |
| Rate for Payer: Aetna Commercial |
$65,142.00
|
| Rate for Payer: Anthem Medicaid |
$29,093.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,988.00
|
| Rate for Payer: Cash Price |
$42,300.00
|
| Rate for Payer: Cigna Commercial |
$70,218.00
|
| Rate for Payer: First Health Commercial |
$80,370.00
|
| Rate for Payer: Humana Commercial |
$71,910.00
|
| Rate for Payer: Humana KY Medicaid |
$29,093.94
|
| Rate for Payer: Kentucky WC Medicaid |
$29,390.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69,372.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62,434.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,380.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,677.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$74,448.00
|
| Rate for Payer: Ohio Health Group HMO |
$63,450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73,602.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,374.00
|
| Rate for Payer: PHCS Commercial |
$81,216.00
|
| Rate for Payer: United Healthcare All Payer |
$74,448.00
|
|
|
VIRTUOSO II DR D274DRG
|
Facility
|
IP
|
$84,600.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$25,380.00 |
| Max. Negotiated Rate |
$81,216.00 |
| Rate for Payer: Aetna Commercial |
$65,142.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,988.00
|
| Rate for Payer: Cash Price |
$42,300.00
|
| Rate for Payer: Cigna Commercial |
$70,218.00
|
| Rate for Payer: First Health Commercial |
$80,370.00
|
| Rate for Payer: Humana Commercial |
$71,910.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69,372.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62,434.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,380.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$74,448.00
|
| Rate for Payer: Ohio Health Group HMO |
$63,450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73,602.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,374.00
|
| Rate for Payer: PHCS Commercial |
$81,216.00
|
| Rate for Payer: United Healthcare All Payer |
$74,448.00
|
|
|
VISCOAT (CHONDROINTIN SO4- 1EA
|
Facility
|
IP
|
$626.27
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
25003576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.88 |
| Max. Negotiated Rate |
$601.22 |
| Rate for Payer: Aetna Commercial |
$482.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$488.49
|
| Rate for Payer: Cash Price |
$313.14
|
| Rate for Payer: Cigna Commercial |
$519.80
|
| Rate for Payer: First Health Commercial |
$594.96
|
| Rate for Payer: Humana Commercial |
$532.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$513.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$462.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$551.12
|
| Rate for Payer: Ohio Health Group HMO |
$469.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$544.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$432.13
|
| Rate for Payer: PHCS Commercial |
$601.22
|
| Rate for Payer: United Healthcare All Payer |
$551.12
|
|
|
VISCOAT (CHONDROINTIN SO4- 1EA
|
Facility
|
OP
|
$626.27
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
25003576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.88 |
| Max. Negotiated Rate |
$601.22 |
| Rate for Payer: Aetna Commercial |
$482.23
|
| Rate for Payer: Anthem Medicaid |
$215.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$488.49
|
| Rate for Payer: Cash Price |
$313.14
|
| Rate for Payer: Cigna Commercial |
$519.80
|
| Rate for Payer: First Health Commercial |
$594.96
|
| Rate for Payer: Humana Commercial |
$532.33
|
| Rate for Payer: Humana KY Medicaid |
$215.37
|
| Rate for Payer: Kentucky WC Medicaid |
$217.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$513.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$462.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$551.12
|
| Rate for Payer: Ohio Health Group HMO |
$469.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$544.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$432.13
|
| Rate for Payer: PHCS Commercial |
$601.22
|
| Rate for Payer: United Healthcare All Payer |
$551.12
|
|
|
VISINE(TETRAHYDROZOLINE) 15ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 536121794
|
| Hospital Charge Code |
25001679
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
VISINE(TETRAHYDROZOLINE) 15ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 536121794
|
| Hospital Charge Code |
25001679
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
VISION BLUE
|
Facility
|
OP
|
$351.90
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
25003577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.57 |
| Max. Negotiated Rate |
$337.82 |
| Rate for Payer: Aetna Commercial |
$270.96
|
| Rate for Payer: Anthem Medicaid |
$121.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$274.48
|
| Rate for Payer: Cash Price |
$175.95
|
| Rate for Payer: Cigna Commercial |
$292.08
|
| Rate for Payer: First Health Commercial |
$334.31
|
| Rate for Payer: Humana Commercial |
$299.12
|
| Rate for Payer: Humana KY Medicaid |
$121.02
|
| Rate for Payer: Kentucky WC Medicaid |
$122.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$288.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$259.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$309.67
|
| Rate for Payer: Ohio Health Group HMO |
$263.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$281.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$306.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.81
|
| Rate for Payer: PHCS Commercial |
$337.82
|
| Rate for Payer: United Healthcare All Payer |
$309.67
|
|
|
VISION BLUE
|
Facility
|
IP
|
$351.90
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
25003577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.57 |
| Max. Negotiated Rate |
$337.82 |
| Rate for Payer: Aetna Commercial |
$270.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$274.48
|
| Rate for Payer: Cash Price |
$175.95
|
| Rate for Payer: Cigna Commercial |
$292.08
|
| Rate for Payer: First Health Commercial |
$334.31
|
| Rate for Payer: Humana Commercial |
$299.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$288.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$259.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$309.67
|
| Rate for Payer: Ohio Health Group HMO |
$263.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$281.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$306.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.81
|
| Rate for Payer: PHCS Commercial |
$337.82
|
| Rate for Payer: United Healthcare All Payer |
$309.67
|
|
|
VISION SCREEN
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
51000058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
VISION SCREEN
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
51000058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$30.05 |
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$8.07
|
| Rate for Payer: Anthem Medicaid |
$15.64
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$25.52
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$15.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$15.95
|
| Rate for Payer: Molina Healthcare Passport |
$15.64
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$8.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.80
|
|
|
VISION SCREEN
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
51000058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$13.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Humana KY Medicaid |
$13.76
|
| Rate for Payer: Kentucky WC Medicaid |
$13.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
VISION SCREEN(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
510P0058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$30.05 |
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$8.07
|
| Rate for Payer: Anthem Medicaid |
$15.64
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$25.52
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$15.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$15.95
|
| Rate for Payer: Molina Healthcare Passport |
$15.64
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$8.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.80
|
|
