|
VIVITROL 1mg (380mg vial)
|
Facility
|
OP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
636T0146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem Medicaid |
$8.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Humana KY Medicaid |
$8.34
|
| Rate for Payer: Humana Medicare Advantage |
$4.24
|
| Rate for Payer: Kentucky WC Medicaid |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
OP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
63600146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem Medicaid |
$8.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Humana KY Medicaid |
$8.34
|
| Rate for Payer: Humana Medicare Advantage |
$4.24
|
| Rate for Payer: Kentucky WC Medicaid |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
OP
|
$9,212.35
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
25004089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$8,843.86 |
| Rate for Payer: Aetna Commercial |
$7,093.51
|
| Rate for Payer: Anthem Medicaid |
$3,168.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,185.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$4,606.18
|
| 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: Humana KY Medicaid |
$3,168.13
|
| Rate for Payer: Humana Medicare Advantage |
$4.24
|
| Rate for Payer: Kentucky WC Medicaid |
$3,200.37
|
| 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 |
$5.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,231.69
|
| 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
|
|
|
VIVITROL 1mg (380mg vial)
|
Professional
|
Both
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
63600146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$14.54 |
| Rate for Payer: Aetna Commercial |
$4.83
|
| Rate for Payer: Ambetter Exchange |
$4.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.09
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Healthspan PPO |
$2.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.24
|
| Rate for Payer: Multiplan PHCS |
$14.54
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.51
|
| Rate for Payer: UHCCP Medicaid |
$8.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.24
|
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
IP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
63600146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
IP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
636T0146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
VIVITY LENS DFT315+14.0
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
VIVITY LENS DFT315+14.0
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
VIVITY LENS DFT315*20.0
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
VIVITY LENS DFT315*20.0
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
VIVITY LENS DFT315*20.5
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
VIVITY LENS DFT315*20.5
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
VIVITY LENS DFT315*22.0
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
VIVITY LENS DFT315*22.0
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
VIVONEX RTF LIQUID 1000 ML
|
Facility
|
OP
|
$95.92
|
|
|
Service Code
|
HCPCS B4153
|
| Hospital Charge Code |
25001807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$92.08 |
| Rate for Payer: Aetna Commercial |
$73.86
|
| Rate for Payer: Anthem Medicaid |
$32.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.82
|
| Rate for Payer: Cash Price |
$47.96
|
| Rate for Payer: Cigna Commercial |
$79.61
|
| Rate for Payer: First Health Commercial |
$91.12
|
| Rate for Payer: Humana Commercial |
$81.53
|
| Rate for Payer: Humana KY Medicaid |
$32.99
|
| Rate for Payer: Kentucky WC Medicaid |
$33.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.41
|
| Rate for Payer: Ohio Health Group HMO |
$71.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.18
|
| Rate for Payer: PHCS Commercial |
$92.08
|
| Rate for Payer: United Healthcare All Payer |
$84.41
|
|
|
VIVONEX RTF LIQUID 1000 ML
|
Facility
|
IP
|
$95.92
|
|
|
Service Code
|
HCPCS B4153
|
| Hospital Charge Code |
25001807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$92.08 |
| Rate for Payer: Aetna Commercial |
$73.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.82
|
| Rate for Payer: Cash Price |
$47.96
|
| Rate for Payer: Cigna Commercial |
$79.61
|
| Rate for Payer: First Health Commercial |
$91.12
|
| Rate for Payer: Humana Commercial |
$81.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.41
|
| Rate for Payer: Ohio Health Group HMO |
$71.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.18
|
| Rate for Payer: PHCS Commercial |
$92.08
|
| Rate for Payer: United Healthcare All Payer |
$84.41
|
|
|
VODA LEFT 3 7F
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
VODA LEFT 3 7F
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
VOICE PROSTH AUG/ALT COMM
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
HCPCS 92597
|
| Hospital Charge Code |
44000008
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$106.80 |
| Max. Negotiated Rate |
$341.76 |
| Rate for Payer: Aetna Commercial |
$274.12
|
| Rate for Payer: Anthem Medicaid |
$122.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.68
|
| Rate for Payer: Cash Price |
$178.00
|
| Rate for Payer: Cigna Commercial |
$295.48
|
| Rate for Payer: First Health Commercial |
$338.20
|
| Rate for Payer: Humana Commercial |
$302.60
|
| Rate for Payer: Humana KY Medicaid |
$122.43
|
| Rate for Payer: Kentucky WC Medicaid |
$123.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$262.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$313.28
|
| Rate for Payer: Ohio Health Group HMO |
$267.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$309.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.64
|
| Rate for Payer: PHCS Commercial |
$341.76
|
| Rate for Payer: United Healthcare All Payer |
$313.28
|
|
|
VOICE PROSTH AUG/ALT COMM
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
HCPCS 92597
|
| Hospital Charge Code |
44000008
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$106.80 |
| Max. Negotiated Rate |
$341.76 |
| Rate for Payer: Aetna Commercial |
$274.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.68
|
| Rate for Payer: Cash Price |
$178.00
|
| Rate for Payer: Cigna Commercial |
$295.48
|
| Rate for Payer: First Health Commercial |
$338.20
|
| Rate for Payer: Humana Commercial |
$302.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$262.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$313.28
|
| Rate for Payer: Ohio Health Group HMO |
$267.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$309.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.64
|
| Rate for Payer: PHCS Commercial |
$341.76
|
| Rate for Payer: United Healthcare All Payer |
$313.28
|
|
|
VOIDING CYSTOGRAM
|
Facility
|
OP
|
$504.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
32000147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$173.33 |
| Max. Negotiated Rate |
$483.84 |
| Rate for Payer: Aetna Commercial |
$388.08
|
| Rate for Payer: Anthem Medicaid |
$173.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$418.32
|
| Rate for Payer: First Health Commercial |
$478.80
|
| Rate for Payer: Humana Commercial |
$428.40
|
| Rate for Payer: Humana KY Medicaid |
$173.33
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$175.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$413.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$176.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$443.52
|
| Rate for Payer: Ohio Health Group HMO |
$378.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$438.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$347.76
|
| Rate for Payer: PHCS Commercial |
$483.84
|
| Rate for Payer: United Healthcare All Payer |
$443.52
|
|
|
VOIDING CYSTOGRAM
|
Professional
|
Both
|
$504.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
32000147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$302.40 |
| Rate for Payer: Aetna Commercial |
$137.30
|
| Rate for Payer: Ambetter Exchange |
$90.61
|
| Rate for Payer: Anthem Medicaid |
$56.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.73
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$123.23
|
| Rate for Payer: Healthspan PPO |
$128.66
|
| Rate for Payer: Humana Medicaid |
$56.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.00
|
| Rate for Payer: Molina Healthcare Passport |
$56.86
|
| Rate for Payer: Multiplan PHCS |
$302.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.79
|
| Rate for Payer: UHCCP Medicaid |
$176.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.43
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.61
|
|
|
VOIDING CYSTOGRAM
|
Facility
|
IP
|
$504.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
32000147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$483.84 |
| Rate for Payer: Aetna Commercial |
$388.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.12
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$418.32
|
| Rate for Payer: First Health Commercial |
$478.80
|
| Rate for Payer: Humana Commercial |
$428.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$413.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$443.52
|
| Rate for Payer: Ohio Health Group HMO |
$378.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$438.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$347.76
|
| Rate for Payer: PHCS Commercial |
$483.84
|
| Rate for Payer: United Healthcare All Payer |
$443.52
|
|
|
VOIDING CYSTOGRAM(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
320P0147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$137.30 |
| Rate for Payer: Aetna Commercial |
$137.30
|
| Rate for Payer: Ambetter Exchange |
$90.61
|
| Rate for Payer: Anthem Medicaid |
$56.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.73
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$123.23
|
| Rate for Payer: Healthspan PPO |
$128.66
|
| Rate for Payer: Humana Medicaid |
$56.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.00
|
| Rate for Payer: Molina Healthcare Passport |
$56.86
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.79
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.43
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.61
|
|
|
VOIDING CYSTOGRAM(T
|
Facility
|
OP
|
$429.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
320T0147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$147.53 |
| Max. Negotiated Rate |
$411.84 |
| Rate for Payer: Aetna Commercial |
$330.33
|
| Rate for Payer: Anthem Medicaid |
$147.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$334.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$214.50
|
| Rate for Payer: Cash Price |
$214.50
|
| Rate for Payer: Cigna Commercial |
$356.07
|
| Rate for Payer: First Health Commercial |
$407.55
|
| Rate for Payer: Humana Commercial |
$364.65
|
| Rate for Payer: Humana KY Medicaid |
$147.53
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$149.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$351.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$316.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$377.52
|
| Rate for Payer: Ohio Health Group HMO |
$321.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$373.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.01
|
| Rate for Payer: PHCS Commercial |
$411.84
|
| Rate for Payer: United Healthcare All Payer |
$377.52
|
|
