|
VISI-PRO STENT 8*27*135
|
Facility
|
OP
|
$4,343.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.12 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna Commercial |
$3,344.69
|
| Rate for Payer: Anthem Medicaid |
$1,493.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,388.12
|
| Rate for Payer: Cash Price |
$2,171.88
|
| Rate for Payer: Cigna Commercial |
$3,605.31
|
| Rate for Payer: First Health Commercial |
$4,126.56
|
| Rate for Payer: Humana Commercial |
$3,692.19
|
| Rate for Payer: Humana KY Medicaid |
$1,493.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,509.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,561.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,205.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,303.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,523.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,822.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,257.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,475.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,779.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,997.19
|
| Rate for Payer: PHCS Commercial |
$4,170.00
|
| Rate for Payer: United Healthcare All Payer |
$3,822.50
|
|
|
VISI-PRO STENT 8*27*135
|
Facility
|
IP
|
$4,343.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.12 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna Commercial |
$3,344.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,388.12
|
| Rate for Payer: Cash Price |
$2,171.88
|
| Rate for Payer: Cigna Commercial |
$3,605.31
|
| Rate for Payer: First Health Commercial |
$4,126.56
|
| Rate for Payer: Humana Commercial |
$3,692.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,561.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,205.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,303.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,822.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,257.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,475.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,779.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,997.19
|
| Rate for Payer: PHCS Commercial |
$4,170.00
|
| Rate for Payer: United Healthcare All Payer |
$3,822.50
|
|
|
VISI-PRO STENT 8*27*80
|
Facility
|
IP
|
$8,237.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,471.32 |
| Max. Negotiated Rate |
$7,908.24 |
| Rate for Payer: Aetna Commercial |
$6,343.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,425.44
|
| Rate for Payer: Cash Price |
$4,118.88
|
| Rate for Payer: Cigna Commercial |
$6,837.33
|
| Rate for Payer: First Health Commercial |
$7,825.86
|
| Rate for Payer: Humana Commercial |
$7,002.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,754.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,079.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,471.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,249.22
|
| Rate for Payer: Ohio Health Group HMO |
$6,178.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,590.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,166.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,684.05
|
| Rate for Payer: PHCS Commercial |
$7,908.24
|
| Rate for Payer: United Healthcare All Payer |
$7,249.22
|
|
|
VISI-PRO STENT 8*27*80
|
Facility
|
OP
|
$8,237.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,471.32 |
| Max. Negotiated Rate |
$7,908.24 |
| Rate for Payer: Aetna Commercial |
$6,343.07
|
| Rate for Payer: Anthem Medicaid |
$2,832.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,425.44
|
| Rate for Payer: Cash Price |
$4,118.88
|
| Rate for Payer: Cigna Commercial |
$6,837.33
|
| Rate for Payer: First Health Commercial |
$7,825.86
|
| Rate for Payer: Humana Commercial |
$7,002.09
|
| Rate for Payer: Humana KY Medicaid |
$2,832.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,861.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,754.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,079.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,471.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,889.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,249.22
|
| Rate for Payer: Ohio Health Group HMO |
$6,178.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,590.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,166.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,684.05
|
| Rate for Payer: PHCS Commercial |
$7,908.24
|
| Rate for Payer: United Healthcare All Payer |
$7,249.22
|
|
|
VISI-PRO STENT 8*37*-135
|
Facility
|
IP
|
$6,795.20
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,038.56 |
| Max. Negotiated Rate |
$6,523.39 |
| Rate for Payer: Aetna Commercial |
$5,232.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.26
|
| Rate for Payer: Cash Price |
$3,397.60
|
| Rate for Payer: Cigna Commercial |
$5,640.02
|
| Rate for Payer: First Health Commercial |
$6,455.44
|
| Rate for Payer: Humana Commercial |
$5,775.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,572.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.69
|
| Rate for Payer: PHCS Commercial |
$6,523.39
|
| Rate for Payer: United Healthcare All Payer |
$5,979.78
|
|
|
VISI-PRO STENT 8*37*-135
|
Facility
|
OP
|
$6,795.20
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,038.56 |
| Max. Negotiated Rate |
$6,523.39 |
| Rate for Payer: Aetna Commercial |
$5,232.30
|
| Rate for Payer: Anthem Medicaid |
$2,336.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.26
|
| Rate for Payer: Cash Price |
$3,397.60
|
| Rate for Payer: Cigna Commercial |
$5,640.02
|
| Rate for Payer: First Health Commercial |
$6,455.44
|
| Rate for Payer: Humana Commercial |
$5,775.92
|
| Rate for Payer: Humana KY Medicaid |
$2,336.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,360.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,572.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,383.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.69
|
| Rate for Payer: PHCS Commercial |
$6,523.39
|
| Rate for Payer: United Healthcare All Payer |
$5,979.78
|
|
|
VISI-PRO STENT 8*37*80
|
Facility
|
OP
|
$4,343.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.12 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna Commercial |
$3,344.69
|
| Rate for Payer: Anthem Medicaid |
$1,493.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,388.12
|
| Rate for Payer: Cash Price |
$2,171.88
|
| Rate for Payer: Cigna Commercial |
$3,605.31
|
| Rate for Payer: First Health Commercial |
$4,126.56
|
| Rate for Payer: Humana Commercial |
$3,692.19
|
| Rate for Payer: Humana KY Medicaid |
$1,493.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,509.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,561.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,205.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,303.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,523.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,822.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,257.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,475.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,779.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,997.19
|
| Rate for Payer: PHCS Commercial |
$4,170.00
|
| Rate for Payer: United Healthcare All Payer |
$3,822.50
|
|
|
VISI-PRO STENT 8*37*80
|
Facility
|
IP
|
$4,343.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.12 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna Commercial |
$3,344.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,388.12
|
| Rate for Payer: Cash Price |
$2,171.88
|
| Rate for Payer: Cigna Commercial |
$3,605.31
|
| Rate for Payer: First Health Commercial |
$4,126.56
|
| Rate for Payer: Humana Commercial |
$3,692.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,561.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,205.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,303.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,822.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,257.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,475.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,779.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,997.19
|
| Rate for Payer: PHCS Commercial |
$4,170.00
|
| Rate for Payer: United Healthcare All Payer |
$3,822.50
|
|
|
VISI-PRO STENT 8*57*80
|
Facility
|
OP
|
$4,343.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.12 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna Commercial |
$3,344.69
|
| Rate for Payer: Anthem Medicaid |
$1,493.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,388.12
|
| Rate for Payer: Cash Price |
$2,171.88
|
| Rate for Payer: Cigna Commercial |
$3,605.31
|
| Rate for Payer: First Health Commercial |
$4,126.56
|
| Rate for Payer: Humana Commercial |
$3,692.19
|
| Rate for Payer: Humana KY Medicaid |
$1,493.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,509.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,561.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,205.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,303.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,523.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,822.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,257.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,475.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,779.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,997.19
|
| Rate for Payer: PHCS Commercial |
$4,170.00
|
| Rate for Payer: United Healthcare All Payer |
$3,822.50
|
|
|
VISI-PRO STENT 8*57*80
|
Facility
|
IP
|
$4,343.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.12 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna Commercial |
$3,344.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,388.12
|
| Rate for Payer: Cash Price |
$2,171.88
|
| Rate for Payer: Cigna Commercial |
$3,605.31
|
| Rate for Payer: First Health Commercial |
$4,126.56
|
| Rate for Payer: Humana Commercial |
$3,692.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,561.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,205.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,303.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,822.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,257.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,475.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,779.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,997.19
|
| Rate for Payer: PHCS Commercial |
$4,170.00
|
| Rate for Payer: United Healthcare All Payer |
$3,822.50
|
|
|
VISI-PRO STENT 9*27*80
|
Facility
|
IP
|
$6,795.20
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,038.56 |
| Max. Negotiated Rate |
$6,523.39 |
| Rate for Payer: Aetna Commercial |
$5,232.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.26
|
| Rate for Payer: Cash Price |
$3,397.60
|
| Rate for Payer: Cigna Commercial |
$5,640.02
|
| Rate for Payer: First Health Commercial |
$6,455.44
|
| Rate for Payer: Humana Commercial |
$5,775.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,572.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.69
|
| Rate for Payer: PHCS Commercial |
$6,523.39
|
| Rate for Payer: United Healthcare All Payer |
$5,979.78
|
|
|
VISI-PRO STENT 9*27*80
|
Facility
|
OP
|
$6,795.20
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,038.56 |
| Max. Negotiated Rate |
$6,523.39 |
| Rate for Payer: Aetna Commercial |
$5,232.30
|
| Rate for Payer: Anthem Medicaid |
$2,336.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.26
|
| Rate for Payer: Cash Price |
$3,397.60
|
| Rate for Payer: Cigna Commercial |
$5,640.02
|
| Rate for Payer: First Health Commercial |
$6,455.44
|
| Rate for Payer: Humana Commercial |
$5,775.92
|
| Rate for Payer: Humana KY Medicaid |
$2,336.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,360.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,572.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,383.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.69
|
| Rate for Payer: PHCS Commercial |
$6,523.39
|
| Rate for Payer: United Healthcare All Payer |
$5,979.78
|
|
|
VISI-PRO STENT 9*37*80
|
Facility
|
OP
|
$4,433.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,330.12 |
| Max. Negotiated Rate |
$4,256.40 |
| Rate for Payer: Aetna Commercial |
$3,413.99
|
| Rate for Payer: Anthem Medicaid |
$1,524.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,458.32
|
| Rate for Payer: Cash Price |
$2,216.88
|
| Rate for Payer: Cigna Commercial |
$3,680.01
|
| Rate for Payer: First Health Commercial |
$4,212.06
|
| Rate for Payer: Humana Commercial |
$3,768.69
|
| Rate for Payer: Humana KY Medicaid |
$1,524.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,540.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,635.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,272.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,330.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,555.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,901.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,325.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,547.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,857.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,059.29
|
| Rate for Payer: PHCS Commercial |
$4,256.40
|
| Rate for Payer: United Healthcare All Payer |
$3,901.70
|
|
|
VISI-PRO STENT 9*37*80
|
Facility
|
IP
|
$4,433.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,330.12 |
| Max. Negotiated Rate |
$4,256.40 |
| Rate for Payer: Aetna Commercial |
$3,413.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,458.32
|
| Rate for Payer: Cash Price |
$2,216.88
|
| Rate for Payer: Cigna Commercial |
$3,680.01
|
| Rate for Payer: First Health Commercial |
$4,212.06
|
| Rate for Payer: Humana Commercial |
$3,768.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,635.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,272.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,330.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,901.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,325.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,547.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,857.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,059.29
|
| Rate for Payer: PHCS Commercial |
$4,256.40
|
| Rate for Payer: United Healthcare All Payer |
$3,901.70
|
|
|
VISI-PRO STENT 9*57*80
|
Facility
|
OP
|
$4,433.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,330.12 |
| Max. Negotiated Rate |
$4,256.40 |
| Rate for Payer: Aetna Commercial |
$3,413.99
|
| Rate for Payer: Anthem Medicaid |
$1,524.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,458.32
|
| Rate for Payer: Cash Price |
$2,216.88
|
| Rate for Payer: Cigna Commercial |
$3,680.01
|
| Rate for Payer: First Health Commercial |
$4,212.06
|
| Rate for Payer: Humana Commercial |
$3,768.69
|
| Rate for Payer: Humana KY Medicaid |
$1,524.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,540.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,635.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,272.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,330.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,555.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,901.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,325.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,547.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,857.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,059.29
|
| Rate for Payer: PHCS Commercial |
$4,256.40
|
| Rate for Payer: United Healthcare All Payer |
$3,901.70
|
|
|
VISI-PRO STENT 9*57*80
|
Facility
|
IP
|
$4,433.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,330.12 |
| Max. Negotiated Rate |
$4,256.40 |
| Rate for Payer: Aetna Commercial |
$3,413.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,458.32
|
| Rate for Payer: Cash Price |
$2,216.88
|
| Rate for Payer: Cigna Commercial |
$3,680.01
|
| Rate for Payer: First Health Commercial |
$4,212.06
|
| Rate for Payer: Humana Commercial |
$3,768.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,635.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,272.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,330.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,901.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,325.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,547.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,857.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,059.29
|
| Rate for Payer: PHCS Commercial |
$4,256.40
|
| Rate for Payer: United Healthcare All Payer |
$3,901.70
|
|
|
VISKEN (PINDOLOL) 5 M 5MG/1TAB
|
Facility
|
IP
|
$4.90
|
|
|
Service Code
|
NDC 62559056001
|
| Hospital Charge Code |
25001680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cigna Commercial |
$4.07
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.31
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Payer |
$4.31
|
|
|
VISKEN (PINDOLOL) 5 M 5MG/1TAB
|
Facility
|
OP
|
$4.90
|
|
|
Service Code
|
NDC 62559056001
|
| Hospital Charge Code |
25001680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cigna Commercial |
$4.07
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.31
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Payer |
$4.31
|
|
|
VISTARIL(HYDROXYZINE 25MG/1CAP
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 185067401
|
| Hospital Charge Code |
25001681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
VISTARIL(HYDROXYZINE 25MG/1CAP
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 185067401
|
| Hospital Charge Code |
25001681
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
VISTARIL(HYDROXYZINE 50MG/1CAP
|
Facility
|
OP
|
$4.63
|
|
|
Service Code
|
NDC 60687070701
|
| Hospital Charge Code |
25001682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
VISTARIL(HYDROXYZINE 50MG/1CAP
|
Facility
|
IP
|
$4.63
|
|
|
Service Code
|
NDC 60687070701
|
| Hospital Charge Code |
25001682
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
IP
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.37 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Aetna Commercial |
$67.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.57
|
| Rate for Payer: Cash Price |
$43.95
|
| Rate for Payer: Cigna Commercial |
$72.97
|
| Rate for Payer: First Health Commercial |
$83.51
|
| Rate for Payer: Humana Commercial |
$74.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.36
|
| Rate for Payer: Ohio Health Group HMO |
$65.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.66
|
| Rate for Payer: PHCS Commercial |
$84.39
|
| Rate for Payer: United Healthcare All Payer |
$77.36
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
OP
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.37 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Aetna Commercial |
$67.69
|
| Rate for Payer: Anthem Medicaid |
$30.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.57
|
| Rate for Payer: Cash Price |
$43.95
|
| Rate for Payer: Cigna Commercial |
$72.97
|
| Rate for Payer: First Health Commercial |
$83.51
|
| Rate for Payer: Humana Commercial |
$74.72
|
| Rate for Payer: Humana KY Medicaid |
$30.23
|
| Rate for Payer: Kentucky WC Medicaid |
$30.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.36
|
| Rate for Payer: Ohio Health Group HMO |
$65.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.66
|
| Rate for Payer: PHCS Commercial |
$84.39
|
| Rate for Payer: United Healthcare All Payer |
$77.36
|
|
|
VISTARIL UP TO 25MG (25MG/ML)
|
Professional
|
Both
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$52.75 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Ambetter Exchange |
$16.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.32
|
| Rate for Payer: Cash Price |
$43.95
|
| Rate for Payer: Cash Price |
$43.95
|
| Rate for Payer: Healthspan PPO |
$0.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$16.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.93
|
| Rate for Payer: Multiplan PHCS |
$52.75
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$22.01
|
| Rate for Payer: UHCCP Medicaid |
$30.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.93
|
|
