|
Vitamin K 1mg (10mg IVPB) ANE
|
Facility
|
IP
|
$321.66
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25004146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.50 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna Commercial |
$247.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.89
|
| Rate for Payer: Cash Price |
$160.83
|
| Rate for Payer: Cigna Commercial |
$266.98
|
| Rate for Payer: First Health Commercial |
$305.58
|
| Rate for Payer: Humana Commercial |
$273.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.06
|
| Rate for Payer: Ohio Health Group HMO |
$241.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$257.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$279.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.95
|
| Rate for Payer: PHCS Commercial |
$308.79
|
| Rate for Payer: United Healthcare All Payer |
$283.06
|
|
|
VITAMIN K1, S
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 84597
|
| Hospital Charge Code |
30001825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$141.12 |
| Rate for Payer: Aetna Commercial |
$113.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.04
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$122.01
|
| Rate for Payer: First Health Commercial |
$139.65
|
| Rate for Payer: Humana Commercial |
$124.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.36
|
| Rate for Payer: Ohio Health Group HMO |
$110.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.43
|
| Rate for Payer: PHCS Commercial |
$141.12
|
| Rate for Payer: United Healthcare All Payer |
$129.36
|
|
|
VITAMIN K1, S
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 84597
|
| Hospital Charge Code |
30001825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$141.12 |
| Rate for Payer: Aetna Commercial |
$113.19
|
| Rate for Payer: Anthem Medicaid |
$13.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.72
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$122.01
|
| Rate for Payer: First Health Commercial |
$139.65
|
| Rate for Payer: Humana Commercial |
$124.95
|
| Rate for Payer: Humana KY Medicaid |
$13.72
|
| Rate for Payer: Humana Medicare Advantage |
$13.72
|
| Rate for Payer: Kentucky WC Medicaid |
$13.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.36
|
| Rate for Payer: Ohio Health Group HMO |
$110.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.43
|
| Rate for Payer: PHCS Commercial |
$141.12
|
| Rate for Payer: United Healthcare All Payer |
$129.36
|
|
|
VITB12(CYANOCOBALAMIN)100MCG T
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 50268085215
|
| Hospital Charge Code |
25001683
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
VITB12(CYANOCOBALAMIN)100MCG T
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 50268085215
|
| Hospital Charge Code |
25001683
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
VITK MG (2.5MG/2.5ML ORAL SOL)
|
Facility
|
OP
|
$292.42
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.73 |
| Max. Negotiated Rate |
$280.72 |
| Rate for Payer: Aetna Commercial |
$225.16
|
| Rate for Payer: Anthem Medicaid |
$100.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$228.09
|
| Rate for Payer: Cash Price |
$146.21
|
| Rate for Payer: Cigna Commercial |
$242.71
|
| Rate for Payer: First Health Commercial |
$277.80
|
| Rate for Payer: Humana Commercial |
$248.56
|
| Rate for Payer: Humana KY Medicaid |
$100.56
|
| Rate for Payer: Kentucky WC Medicaid |
$101.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$257.33
|
| Rate for Payer: Ohio Health Group HMO |
$219.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$254.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.77
|
| Rate for Payer: PHCS Commercial |
$280.72
|
| Rate for Payer: United Healthcare All Payer |
$257.33
|
|
|
VITK MG (2.5MG/2.5ML ORAL SOL)
|
Facility
|
IP
|
$292.42
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.73 |
| Max. Negotiated Rate |
$280.72 |
| Rate for Payer: Aetna Commercial |
$225.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$228.09
|
| Rate for Payer: Cash Price |
$146.21
|
| Rate for Payer: Cigna Commercial |
$242.71
|
| Rate for Payer: First Health Commercial |
$277.80
|
| Rate for Payer: Humana Commercial |
$248.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$257.33
|
| Rate for Payer: Ohio Health Group HMO |
$219.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$254.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.77
|
| Rate for Payer: PHCS Commercial |
$280.72
|
| Rate for Payer: United Healthcare All Payer |
$257.33
|
|
|
VITOSS BA2X BONE GRAFT 10CC
|
Facility
|
IP
|
$27,185.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,155.50 |
| Max. Negotiated Rate |
$26,097.60 |
| Rate for Payer: Aetna Commercial |
$20,932.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,204.30
|
| Rate for Payer: Cash Price |
$13,592.50
|
| Rate for Payer: Cigna Commercial |
$22,563.55
|
| Rate for Payer: First Health Commercial |
$25,825.75
|
| Rate for Payer: Humana Commercial |
$23,107.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,291.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,062.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,155.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,922.80
|
| Rate for Payer: Ohio Health Group HMO |
$20,388.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,748.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,650.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,757.65
|
| Rate for Payer: PHCS Commercial |
$26,097.60
|
| Rate for Payer: United Healthcare All Payer |
$23,922.80
|
|
|
VITOSS BA2X BONE GRAFT 10CC
|
Facility
|
OP
|
$27,185.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,155.50 |
| Max. Negotiated Rate |
$26,097.60 |
| Rate for Payer: Aetna Commercial |
$20,932.45
|
| Rate for Payer: Anthem Medicaid |
$9,348.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,204.30
|
| Rate for Payer: Cash Price |
$13,592.50
|
| Rate for Payer: Cigna Commercial |
$22,563.55
|
| Rate for Payer: First Health Commercial |
$25,825.75
|
| Rate for Payer: Humana Commercial |
$23,107.25
|
| Rate for Payer: Humana KY Medicaid |
$9,348.92
|
| Rate for Payer: Kentucky WC Medicaid |
$9,444.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,291.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,062.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,155.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,536.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,922.80
|
| Rate for Payer: Ohio Health Group HMO |
$20,388.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,748.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,650.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,757.65
|
| Rate for Payer: PHCS Commercial |
$26,097.60
|
| Rate for Payer: United Healthcare All Payer |
$23,922.80
|
|
|
VITOSS BA2X BONE GRAFT 1.2CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
VITOSS BA2X BONE GRAFT 1.2CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
VITOSS BA2X BONE GRAFT 2.5CC
|
Facility
|
IP
|
$9,172.15
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,751.64 |
| Max. Negotiated Rate |
$8,805.26 |
| Rate for Payer: Aetna Commercial |
$7,062.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,154.28
|
| Rate for Payer: Cash Price |
$4,586.08
|
| Rate for Payer: Cigna Commercial |
$7,612.88
|
| Rate for Payer: First Health Commercial |
$8,713.54
|
| Rate for Payer: Humana Commercial |
$7,796.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,521.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,769.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,751.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,071.49
|
| Rate for Payer: Ohio Health Group HMO |
$6,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,337.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,979.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,328.78
|
| Rate for Payer: PHCS Commercial |
$8,805.26
|
| Rate for Payer: United Healthcare All Payer |
$8,071.49
|
|
|
VITOSS BA2X BONE GRAFT 2.5CC
|
Facility
|
OP
|
$9,172.15
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,751.64 |
| Max. Negotiated Rate |
$8,805.26 |
| Rate for Payer: Aetna Commercial |
$7,062.56
|
| Rate for Payer: Anthem Medicaid |
$3,154.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,154.28
|
| Rate for Payer: Cash Price |
$4,586.08
|
| Rate for Payer: Cigna Commercial |
$7,612.88
|
| Rate for Payer: First Health Commercial |
$8,713.54
|
| Rate for Payer: Humana Commercial |
$7,796.33
|
| Rate for Payer: Humana KY Medicaid |
$3,154.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3,186.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,521.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,769.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,751.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,217.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,071.49
|
| Rate for Payer: Ohio Health Group HMO |
$6,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,337.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,979.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,328.78
|
| Rate for Payer: PHCS Commercial |
$8,805.26
|
| Rate for Payer: United Healthcare All Payer |
$8,071.49
|
|
|
VITOSS BA2X BONE GRAFT 5CC
|
Facility
|
IP
|
$12,946.58
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,883.97 |
| Max. Negotiated Rate |
$12,428.72 |
| Rate for Payer: Aetna Commercial |
$9,968.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,098.33
|
| Rate for Payer: Cash Price |
$6,473.29
|
| Rate for Payer: Cigna Commercial |
$10,745.66
|
| Rate for Payer: First Health Commercial |
$12,299.25
|
| Rate for Payer: Humana Commercial |
$11,004.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,616.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,554.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,883.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,392.99
|
| Rate for Payer: Ohio Health Group HMO |
$9,709.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,357.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,263.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,933.14
|
| Rate for Payer: PHCS Commercial |
$12,428.72
|
| Rate for Payer: United Healthcare All Payer |
$11,392.99
|
|
|
VITOSS BA2X BONE GRAFT 5CC
|
Facility
|
OP
|
$12,946.58
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,883.97 |
| Max. Negotiated Rate |
$12,428.72 |
| Rate for Payer: Aetna Commercial |
$9,968.87
|
| Rate for Payer: Anthem Medicaid |
$4,452.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,098.33
|
| Rate for Payer: Cash Price |
$6,473.29
|
| Rate for Payer: Cigna Commercial |
$10,745.66
|
| Rate for Payer: First Health Commercial |
$12,299.25
|
| Rate for Payer: Humana Commercial |
$11,004.59
|
| Rate for Payer: Humana KY Medicaid |
$4,452.33
|
| Rate for Payer: Kentucky WC Medicaid |
$4,497.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,616.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,554.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,883.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,541.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,392.99
|
| Rate for Payer: Ohio Health Group HMO |
$9,709.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,357.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,263.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,933.14
|
| Rate for Payer: PHCS Commercial |
$12,428.72
|
| Rate for Payer: United Healthcare All Payer |
$11,392.99
|
|
|
VITOSS CANISTER 15CC 1-4MM
|
Facility
|
IP
|
$7,307.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,192.10 |
| Max. Negotiated Rate |
$7,014.72 |
| Rate for Payer: Aetna Commercial |
$5,626.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,699.46
|
| Rate for Payer: Cash Price |
$3,653.50
|
| Rate for Payer: Cigna Commercial |
$6,064.81
|
| Rate for Payer: First Health Commercial |
$6,941.65
|
| Rate for Payer: Humana Commercial |
$6,210.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,192.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,430.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,480.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,357.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.83
|
| Rate for Payer: PHCS Commercial |
$7,014.72
|
| Rate for Payer: United Healthcare All Payer |
$6,430.16
|
|
|
VITOSS CANISTER 15CC 1-4MM
|
Facility
|
OP
|
$7,307.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,192.10 |
| Max. Negotiated Rate |
$7,014.72 |
| Rate for Payer: Aetna Commercial |
$5,626.39
|
| Rate for Payer: Anthem Medicaid |
$2,512.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,699.46
|
| Rate for Payer: Cash Price |
$3,653.50
|
| Rate for Payer: Cigna Commercial |
$6,064.81
|
| Rate for Payer: First Health Commercial |
$6,941.65
|
| Rate for Payer: Humana Commercial |
$6,210.95
|
| Rate for Payer: Humana KY Medicaid |
$2,512.88
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,192.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,430.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,480.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,357.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.83
|
| Rate for Payer: PHCS Commercial |
$7,014.72
|
| Rate for Payer: United Healthcare All Payer |
$6,430.16
|
|
|
VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;
|
Facility
|
OP
|
$5,203.86
|
|
|
Service Code
|
CPT 67036
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,717.04 |
| Max. Negotiated Rate |
$5,203.86 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,717.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5,203.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,018.00
|
| Rate for Payer: Humana Medicare Advantage |
$3,717.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,460.45
|
|
|
VIVACTIL 10MG TABLET
|
Facility
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 54021125
|
| Hospital Charge Code |
25001695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: Aetna Commercial |
$9.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
| Rate for Payer: Cash Price |
$6.39
|
| Rate for Payer: Cigna Commercial |
$10.61
|
| Rate for Payer: First Health Commercial |
$12.14
|
| Rate for Payer: Humana Commercial |
$10.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
| Rate for Payer: Ohio Health Group HMO |
$9.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.82
|
| Rate for Payer: PHCS Commercial |
$12.27
|
| Rate for Payer: United Healthcare All Payer |
$11.25
|
|
|
VIVACTIL 10MG TABLET
|
Facility
|
OP
|
$12.78
|
|
|
Service Code
|
NDC 54021125
|
| Hospital Charge Code |
25001695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: Aetna Commercial |
$9.84
|
| Rate for Payer: Anthem Medicaid |
$4.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
| Rate for Payer: Cash Price |
$6.39
|
| Rate for Payer: Cigna Commercial |
$10.61
|
| Rate for Payer: First Health Commercial |
$12.14
|
| Rate for Payer: Humana Commercial |
$10.86
|
| Rate for Payer: Humana KY Medicaid |
$4.40
|
| Rate for Payer: Kentucky WC Medicaid |
$4.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
| Rate for Payer: Ohio Health Group HMO |
$9.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.82
|
| Rate for Payer: PHCS Commercial |
$12.27
|
| Rate for Payer: United Healthcare All Payer |
$11.25
|
|
|
VIVACTIL 5MG TABLET
|
Facility
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 54021025
|
| Hospital Charge Code |
25001696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: Aetna Commercial |
$9.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
| Rate for Payer: Cash Price |
$6.39
|
| Rate for Payer: Cigna Commercial |
$10.61
|
| Rate for Payer: First Health Commercial |
$12.14
|
| Rate for Payer: Humana Commercial |
$10.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
| Rate for Payer: Ohio Health Group HMO |
$9.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.82
|
| Rate for Payer: PHCS Commercial |
$12.27
|
| Rate for Payer: United Healthcare All Payer |
$11.25
|
|
|
VIVACTIL 5MG TABLET
|
Facility
|
OP
|
$12.78
|
|
|
Service Code
|
NDC 54021025
|
| Hospital Charge Code |
25001696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: Aetna Commercial |
$9.84
|
| Rate for Payer: Anthem Medicaid |
$4.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
| Rate for Payer: Cash Price |
$6.39
|
| Rate for Payer: Cigna Commercial |
$10.61
|
| Rate for Payer: First Health Commercial |
$12.14
|
| Rate for Payer: Humana Commercial |
$10.86
|
| Rate for Payer: Humana KY Medicaid |
$4.40
|
| Rate for Payer: Kentucky WC Medicaid |
$4.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
| Rate for Payer: Ohio Health Group HMO |
$9.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.82
|
| Rate for Payer: PHCS Commercial |
$12.27
|
| Rate for Payer: United Healthcare All Payer |
$11.25
|
|
|
VIVARIN (CAFFEINE)200MG TABLET
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 46017001816
|
| Hospital Charge Code |
25001697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
VIVARIN (CAFFEINE)200MG TABLET
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 46017001816
|
| Hospital Charge Code |
25001697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
IP
|
$9,212.35
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
25004089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,763.70 |
| Max. Negotiated Rate |
$8,843.86 |
| Rate for Payer: Aetna Commercial |
$7,093.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,185.63
|
| Rate for Payer: Cash Price |
$4,606.18
|
| Rate for Payer: Cigna Commercial |
$7,646.25
|
| Rate for Payer: First Health Commercial |
$8,751.73
|
| Rate for Payer: Humana Commercial |
$7,830.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,554.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,798.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,763.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,106.87
|
| Rate for Payer: Ohio Health Group HMO |
$6,909.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,369.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,014.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,356.52
|
| Rate for Payer: PHCS Commercial |
$8,843.86
|
| Rate for Payer: United Healthcare All Payer |
$8,106.87
|
|
