|
VISTARIL UP TO 25MG (25MG/ML)
|
Facility
|
OP
|
$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 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)
|
Facility
|
IP
|
$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 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 (50MG/ML)
|
Facility
|
IP
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600065
|
|
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 (50MG/ML)
|
Professional
|
Both
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600065
|
|
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
|
|
|
VISTARIL UP TO 25MG (50MG/ML)
|
Facility
|
OP
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
63600065
|
|
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 (50MG/ML)
|
Facility
|
IP
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0065
|
|
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 (50MG/ML)
|
Facility
|
OP
|
$87.91
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
636T0065
|
|
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
|
|
|
VISTASEAL FIBRIN SEAL 2ML SYR
|
Facility
|
OP
|
$290.55
|
|
|
Service Code
|
NDC 61953001101
|
| Hospital Charge Code |
25003987
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.17 |
| Max. Negotiated Rate |
$278.93 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Anthem Medicaid |
$99.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.63
|
| Rate for Payer: Cash Price |
$145.28
|
| Rate for Payer: Cigna Commercial |
$241.16
|
| Rate for Payer: First Health Commercial |
$276.02
|
| Rate for Payer: Humana Commercial |
$246.97
|
| Rate for Payer: Humana KY Medicaid |
$99.92
|
| Rate for Payer: Kentucky WC Medicaid |
$100.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$101.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$255.68
|
| Rate for Payer: Ohio Health Group HMO |
$217.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$200.48
|
| Rate for Payer: PHCS Commercial |
$278.93
|
| Rate for Payer: United Healthcare All Payer |
$255.68
|
|
|
VISTASEAL FIBRIN SEAL 2ML SYR
|
Facility
|
IP
|
$290.55
|
|
|
Service Code
|
NDC 61953001101
|
| Hospital Charge Code |
25003987
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.17 |
| Max. Negotiated Rate |
$278.93 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.63
|
| Rate for Payer: Cash Price |
$145.28
|
| Rate for Payer: Cigna Commercial |
$241.16
|
| Rate for Payer: First Health Commercial |
$276.02
|
| Rate for Payer: Humana Commercial |
$246.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$255.68
|
| Rate for Payer: Ohio Health Group HMO |
$217.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$200.48
|
| Rate for Payer: PHCS Commercial |
$278.93
|
| Rate for Payer: United Healthcare All Payer |
$255.68
|
|
|
VISTASEAL FIBRIN SEAL 4ML SYR
|
Facility
|
IP
|
$393.24
|
|
|
Service Code
|
NDC 61953001201
|
| Hospital Charge Code |
25003988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.97 |
| Max. Negotiated Rate |
$377.51 |
| Rate for Payer: Aetna Commercial |
$302.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$306.73
|
| Rate for Payer: Cash Price |
$196.62
|
| Rate for Payer: Cigna Commercial |
$326.39
|
| Rate for Payer: First Health Commercial |
$373.58
|
| Rate for Payer: Humana Commercial |
$334.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$322.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.05
|
| Rate for Payer: Ohio Health Group HMO |
$294.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$314.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.34
|
| Rate for Payer: PHCS Commercial |
$377.51
|
| Rate for Payer: United Healthcare All Payer |
$346.05
|
|
|
VISTASEAL FIBRIN SEAL 4ML SYR
|
Facility
|
OP
|
$393.24
|
|
|
Service Code
|
NDC 61953001201
|
| Hospital Charge Code |
25003988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.97 |
| Max. Negotiated Rate |
$377.51 |
| Rate for Payer: Aetna Commercial |
$302.79
|
| Rate for Payer: Anthem Medicaid |
$135.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$306.73
|
| Rate for Payer: Cash Price |
$196.62
|
| Rate for Payer: Cigna Commercial |
$326.39
|
| Rate for Payer: First Health Commercial |
$373.58
|
| Rate for Payer: Humana Commercial |
$334.25
|
| Rate for Payer: Humana KY Medicaid |
$135.24
|
| Rate for Payer: Kentucky WC Medicaid |
$136.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$322.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$137.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.05
|
| Rate for Payer: Ohio Health Group HMO |
$294.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$314.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.34
|
| Rate for Payer: PHCS Commercial |
$377.51
|
| Rate for Payer: United Healthcare All Payer |
$346.05
|
|
|
VISTASEAL FIBRIN SEALANT 10 ML
|
Facility
|
OP
|
$702.30
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.69 |
| Max. Negotiated Rate |
$674.21 |
| Rate for Payer: Aetna Commercial |
$540.77
|
| Rate for Payer: Anthem Medicaid |
$241.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$547.79
|
| Rate for Payer: Cash Price |
$351.15
|
| Rate for Payer: Cigna Commercial |
$582.91
|
| Rate for Payer: First Health Commercial |
$667.18
|
| Rate for Payer: Humana Commercial |
$596.96
|
| Rate for Payer: Humana KY Medicaid |
$241.52
|
| Rate for Payer: Kentucky WC Medicaid |
$243.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$575.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$518.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$246.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$618.02
|
| Rate for Payer: Ohio Health Group HMO |
$526.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$561.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$484.59
|
| Rate for Payer: PHCS Commercial |
$674.21
|
| Rate for Payer: United Healthcare All Payer |
$618.02
|
|
|
VISTASEAL FIBRIN SEALANT 10 ML
|
Facility
|
IP
|
$702.30
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.69 |
| Max. Negotiated Rate |
$674.21 |
| Rate for Payer: Aetna Commercial |
$540.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$547.79
|
| Rate for Payer: Cash Price |
$351.15
|
| Rate for Payer: Cigna Commercial |
$582.91
|
| Rate for Payer: First Health Commercial |
$667.18
|
| Rate for Payer: Humana Commercial |
$596.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$575.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$518.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$618.02
|
| Rate for Payer: Ohio Health Group HMO |
$526.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$561.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$484.59
|
| Rate for Payer: PHCS Commercial |
$674.21
|
| Rate for Payer: United Healthcare All Payer |
$618.02
|
|
|
VISTIDE(CIDOFOVIR)375MG/ML VL
|
Facility
|
OP
|
$4,033.00
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
25001962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$529.38 |
| Max. Negotiated Rate |
$3,871.68 |
| Rate for Payer: Aetna Commercial |
$3,105.41
|
| Rate for Payer: Anthem Medicaid |
$1,386.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$529.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,145.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$741.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$714.66
|
| Rate for Payer: Cash Price |
$2,016.50
|
| Rate for Payer: Cash Price |
$2,016.50
|
| Rate for Payer: Cigna Commercial |
$3,347.39
|
| Rate for Payer: First Health Commercial |
$3,831.35
|
| Rate for Payer: Humana Commercial |
$3,428.05
|
| Rate for Payer: Humana KY Medicaid |
$1,386.95
|
| Rate for Payer: Humana Medicare Advantage |
$529.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1,401.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,307.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,976.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$635.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,414.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,549.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,024.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,226.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,508.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,782.77
|
| Rate for Payer: PHCS Commercial |
$3,871.68
|
| Rate for Payer: United Healthcare All Payer |
$3,549.04
|
|
|
VISTIDE(CIDOFOVIR)375MG/ML VL
|
Facility
|
IP
|
$4,033.00
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
25001962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,209.90 |
| Max. Negotiated Rate |
$3,871.68 |
| Rate for Payer: Aetna Commercial |
$3,105.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,145.74
|
| Rate for Payer: Cash Price |
$2,016.50
|
| Rate for Payer: Cigna Commercial |
$3,347.39
|
| Rate for Payer: First Health Commercial |
$3,831.35
|
| Rate for Payer: Humana Commercial |
$3,428.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,307.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,976.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,209.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,549.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,024.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,226.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,508.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,782.77
|
| Rate for Payer: PHCS Commercial |
$3,871.68
|
| Rate for Payer: United Healthcare All Payer |
$3,549.04
|
|
|
VISUAL ACUITY SCREEN
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
51000059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$68.16 |
| Rate for Payer: Aetna Commercial |
$54.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.38
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cigna Commercial |
$58.93
|
| Rate for Payer: First Health Commercial |
$67.45
|
| Rate for Payer: Humana Commercial |
$60.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.48
|
| Rate for Payer: Ohio Health Group HMO |
$53.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.99
|
| Rate for Payer: PHCS Commercial |
$68.16
|
| Rate for Payer: United Healthcare All Payer |
$62.48
|
|
|
VISUAL ACUITY SCREEN
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
51000059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$68.16 |
| Rate for Payer: Aetna Commercial |
$54.67
|
| Rate for Payer: Anthem Medicaid |
$24.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.38
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cigna Commercial |
$58.93
|
| Rate for Payer: First Health Commercial |
$67.45
|
| Rate for Payer: Humana Commercial |
$60.35
|
| Rate for Payer: Humana KY Medicaid |
$24.42
|
| Rate for Payer: Kentucky WC Medicaid |
$24.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.48
|
| Rate for Payer: Ohio Health Group HMO |
$53.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.99
|
| Rate for Payer: PHCS Commercial |
$68.16
|
| Rate for Payer: United Healthcare All Payer |
$62.48
|
|
|
VISUAL ACUITY SCREEN
|
Professional
|
Both
|
$71.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
51000059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$60.00
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cash Price |
$35.50
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: Healthspan PPO |
$3.45
|
| Rate for Payer: Humana Medicaid |
$60.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.20
|
| Rate for Payer: Molina Healthcare Passport |
$60.00
|
| Rate for Payer: Multiplan PHCS |
$42.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.70
|
| Rate for Payer: UHCCP Medicaid |
$24.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.60
|
|
|
VISUAL ACUITY SCREEN(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
510P0059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$60.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: Healthspan PPO |
$3.45
|
| Rate for Payer: Humana Medicaid |
$60.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.20
|
| Rate for Payer: Molina Healthcare Passport |
$60.00
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.60
|
|
|
VISUAL ACUITY SCREEN(T
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
510T0059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$29.76 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.18
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$25.73
|
| Rate for Payer: First Health Commercial |
$29.45
|
| Rate for Payer: Humana Commercial |
$26.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.28
|
| Rate for Payer: Ohio Health Group HMO |
$23.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$29.76
|
| Rate for Payer: United Healthcare All Payer |
$27.28
|
|
|
VISUAL ACUITY SCREEN(T
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
510T0059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$29.76 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Anthem Medicaid |
$10.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.18
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$25.73
|
| Rate for Payer: First Health Commercial |
$29.45
|
| Rate for Payer: Humana Commercial |
$26.35
|
| Rate for Payer: Humana KY Medicaid |
$10.66
|
| Rate for Payer: Kentucky WC Medicaid |
$10.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.28
|
| Rate for Payer: Ohio Health Group HMO |
$23.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$29.76
|
| Rate for Payer: United Healthcare All Payer |
$27.28
|
|
|
VISUAL AUDIOMETRY
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
HCPCS 92579
|
| Hospital Charge Code |
47000015
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$121.05 |
| Max. Negotiated Rate |
$337.92 |
| Rate for Payer: Aetna Commercial |
$271.04
|
| Rate for Payer: Anthem Medicaid |
$121.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$274.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cigna Commercial |
$292.16
|
| Rate for Payer: First Health Commercial |
$334.40
|
| Rate for Payer: Humana Commercial |
$299.20
|
| Rate for Payer: Humana KY Medicaid |
$121.05
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$122.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$288.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$259.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$309.76
|
| Rate for Payer: Ohio Health Group HMO |
$264.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$281.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$306.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.88
|
| Rate for Payer: PHCS Commercial |
$337.92
|
| Rate for Payer: United Healthcare All Payer |
$309.76
|
|
|
VISUAL AUDIOMETRY
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
HCPCS 92579
|
| Hospital Charge Code |
47000015
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$105.60 |
| Max. Negotiated Rate |
$337.92 |
| Rate for Payer: Aetna Commercial |
$271.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$274.56
|
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cigna Commercial |
$292.16
|
| Rate for Payer: First Health Commercial |
$334.40
|
| Rate for Payer: Humana Commercial |
$299.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$288.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$259.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$309.76
|
| Rate for Payer: Ohio Health Group HMO |
$264.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$281.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$306.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.88
|
| Rate for Payer: PHCS Commercial |
$337.92
|
| Rate for Payer: United Healthcare All Payer |
$309.76
|
|
|
VISUAL FLD EXAM
|
Facility
|
IP
|
$251.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
76102448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.45 |
| Max. Negotiated Rate |
$241.44 |
| Rate for Payer: Aetna Commercial |
$193.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.17
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cigna Commercial |
$208.75
|
| Rate for Payer: First Health Commercial |
$238.93
|
| Rate for Payer: Humana Commercial |
$213.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.32
|
| Rate for Payer: Ohio Health Group HMO |
$188.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.53
|
| Rate for Payer: PHCS Commercial |
$241.44
|
| Rate for Payer: United Healthcare All Payer |
$221.32
|
|
|
VISUAL FLD EXAM
|
Professional
|
Both
|
$251.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
76102448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$150.90 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Ambetter Exchange |
$30.41
|
| Rate for Payer: Anthem Medicaid |
$36.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$30.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$30.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.49
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cigna Commercial |
$69.26
|
| Rate for Payer: Healthspan PPO |
$59.78
|
| Rate for Payer: Humana Medicaid |
$36.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$30.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.18
|
| Rate for Payer: Molina Healthcare Passport |
$36.45
|
| Rate for Payer: Multiplan PHCS |
$150.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$39.53
|
| Rate for Payer: UHCCP Medicaid |
$88.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$30.41
|
|
