|
VOIDING CYSTOGRAM(T
|
Facility
|
IP
|
$429.00
|
|
|
Service Code
|
HCPCS 74455
|
| Hospital Charge Code |
320T0147
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.70 |
| Max. Negotiated Rate |
$411.84 |
| Rate for Payer: Aetna Commercial |
$330.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$334.62
|
| 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: 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 |
$128.70
|
| 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
|
|
|
VOLTAREN 1% GEL (100GM)
|
Facility
|
IP
|
$0.89
|
|
|
Service Code
|
NDC 67815203
|
| Hospital Charge Code |
25001702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna Commercial |
$0.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna Commercial |
$0.74
|
| Rate for Payer: First Health Commercial |
$0.85
|
| Rate for Payer: Humana Commercial |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.78
|
| Rate for Payer: Ohio Health Group HMO |
$0.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.61
|
| Rate for Payer: PHCS Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Payer |
$0.78
|
|
|
VOLTAREN 1% GEL (100GM)
|
Facility
|
OP
|
$0.89
|
|
|
Service Code
|
NDC 67815203
|
| Hospital Charge Code |
25001702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna Commercial |
$0.69
|
| Rate for Payer: Anthem Medicaid |
$0.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna Commercial |
$0.74
|
| Rate for Payer: First Health Commercial |
$0.85
|
| Rate for Payer: Humana Commercial |
$0.76
|
| Rate for Payer: Humana KY Medicaid |
$0.31
|
| Rate for Payer: Kentucky WC Medicaid |
$0.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.78
|
| Rate for Payer: Ohio Health Group HMO |
$0.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.61
|
| Rate for Payer: PHCS Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Payer |
$0.78
|
|
|
VOLTAREN 1% GEL (50 GM)
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 67815202
|
| Hospital Charge Code |
25004468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Anthem Medicaid |
$0.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.31
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna Commercial |
$1.39
|
| Rate for Payer: First Health Commercial |
$1.60
|
| Rate for Payer: Humana Commercial |
$1.43
|
| Rate for Payer: Humana KY Medicaid |
$0.58
|
| Rate for Payer: Kentucky WC Medicaid |
$0.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.48
|
| Rate for Payer: Ohio Health Group HMO |
$1.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.16
|
| Rate for Payer: PHCS Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Payer |
$1.48
|
|
|
VOLTAREN 1% GEL (50 GM)
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 67815202
|
| Hospital Charge Code |
25004468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.31
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna Commercial |
$1.39
|
| Rate for Payer: First Health Commercial |
$1.60
|
| Rate for Payer: Humana Commercial |
$1.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.48
|
| Rate for Payer: Ohio Health Group HMO |
$1.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.16
|
| Rate for Payer: PHCS Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Payer |
$1.48
|
|
|
VOLTAREN (DICLOFENAC) 0. 2.5ML
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
25001701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.33
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna Commercial |
$1.42
|
| Rate for Payer: First Health Commercial |
$1.62
|
| Rate for Payer: Humana Commercial |
$1.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.50
|
| Rate for Payer: Ohio Health Group HMO |
$1.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.18
|
| Rate for Payer: PHCS Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Payer |
$1.50
|
|
|
VOLTAREN (DICLOFENAC) 0. 2.5ML
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
25001701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Anthem Medicaid |
$0.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.33
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna Commercial |
$1.42
|
| Rate for Payer: First Health Commercial |
$1.62
|
| Rate for Payer: Humana Commercial |
$1.45
|
| Rate for Payer: Humana KY Medicaid |
$0.59
|
| Rate for Payer: Kentucky WC Medicaid |
$0.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.50
|
| Rate for Payer: Ohio Health Group HMO |
$1.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.18
|
| Rate for Payer: PHCS Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Payer |
$1.50
|
|
|
VOLTAREN (DICLOFENAC 50MG/1TAB
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 16571020210
|
| Hospital Charge Code |
25001699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
VOLTAREN (DICLOFENAC 50MG/1TAB
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 16571020210
|
| Hospital Charge Code |
25001699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
VOLTAREN (DICLOFENAC 75MG/1TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 68001028100
|
| Hospital Charge Code |
25001700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
VOLTAREN (DICLOFENAC 75MG/1TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 68001028100
|
| Hospital Charge Code |
25001700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
VOLUME ORAL SUSP 450 ML 1%
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
25003648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$23.14 |
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Anthem Medicaid |
$8.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.80
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cigna Commercial |
$20.00
|
| Rate for Payer: First Health Commercial |
$22.89
|
| Rate for Payer: Humana Commercial |
$20.48
|
| Rate for Payer: Humana KY Medicaid |
$8.29
|
| Rate for Payer: Kentucky WC Medicaid |
$8.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.21
|
| Rate for Payer: Ohio Health Group HMO |
$18.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.63
|
| Rate for Payer: PHCS Commercial |
$23.14
|
| Rate for Payer: United Healthcare All Payer |
$21.21
|
|
|
VOLUME ORAL SUSP 450 ML 1%
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
NDC 32909092703
|
| Hospital Charge Code |
25003648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$23.14 |
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.80
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cigna Commercial |
$20.00
|
| Rate for Payer: First Health Commercial |
$22.89
|
| Rate for Payer: Humana Commercial |
$20.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.21
|
| Rate for Payer: Ohio Health Group HMO |
$18.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.63
|
| Rate for Payer: PHCS Commercial |
$23.14
|
| Rate for Payer: United Healthcare All Payer |
$21.21
|
|
|
VOSPIRE ER 4MG(ALBUTEROL SULF)
|
Facility
|
IP
|
$9.43
|
|
|
Service Code
|
NDC 378412201
|
| Hospital Charge Code |
25001703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: First Health Commercial |
$8.96
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.51
|
| Rate for Payer: PHCS Commercial |
$9.05
|
| Rate for Payer: United Healthcare All Payer |
$8.30
|
|
|
VOSPIRE ER 4MG(ALBUTEROL SULF)
|
Facility
|
OP
|
$9.43
|
|
|
Service Code
|
NDC 378412201
|
| Hospital Charge Code |
25001703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Anthem Medicaid |
$3.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: First Health Commercial |
$8.96
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Humana KY Medicaid |
$3.24
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.51
|
| Rate for Payer: PHCS Commercial |
$9.05
|
| Rate for Payer: United Healthcare All Payer |
$8.30
|
|
|
VPRIV 100 UNITS (400 UNIT VL)
|
Facility
|
IP
|
$8,202.30
|
|
|
Service Code
|
HCPCS J3385
|
| Hospital Charge Code |
25002420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,460.69 |
| Max. Negotiated Rate |
$7,874.21 |
| Rate for Payer: Aetna Commercial |
$6,315.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,397.79
|
| Rate for Payer: Cash Price |
$4,101.15
|
| Rate for Payer: Cigna Commercial |
$6,807.91
|
| Rate for Payer: First Health Commercial |
$7,792.19
|
| Rate for Payer: Humana Commercial |
$6,971.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,053.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,218.02
|
| Rate for Payer: Ohio Health Group HMO |
$6,151.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,136.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,659.59
|
| Rate for Payer: PHCS Commercial |
$7,874.21
|
| Rate for Payer: United Healthcare All Payer |
$7,218.02
|
|
|
VPRIV 100 UNITS (400 UNIT VL)
|
Facility
|
OP
|
$8,202.30
|
|
|
Service Code
|
HCPCS J3385
|
| Hospital Charge Code |
25002420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$380.18 |
| Max. Negotiated Rate |
$7,874.21 |
| Rate for Payer: Aetna Commercial |
$6,315.77
|
| Rate for Payer: Anthem Medicaid |
$2,820.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$380.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,397.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$532.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$513.24
|
| Rate for Payer: Cash Price |
$4,101.15
|
| Rate for Payer: Cash Price |
$4,101.15
|
| Rate for Payer: Cigna Commercial |
$6,807.91
|
| Rate for Payer: First Health Commercial |
$7,792.19
|
| Rate for Payer: Humana Commercial |
$6,971.95
|
| Rate for Payer: Humana KY Medicaid |
$2,820.77
|
| Rate for Payer: Humana Medicare Advantage |
$380.18
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,053.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,218.02
|
| Rate for Payer: Ohio Health Group HMO |
$6,151.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,136.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,659.59
|
| Rate for Payer: PHCS Commercial |
$7,874.21
|
| Rate for Payer: United Healthcare All Payer |
$7,218.02
|
|
|
VRAYLAR 1.5MG CAPSULE
|
Facility
|
IP
|
$83.92
|
|
|
Service Code
|
NDC 61874011511
|
| Hospital Charge Code |
25003588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.18 |
| Max. Negotiated Rate |
$80.56 |
| Rate for Payer: Aetna Commercial |
$64.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.46
|
| Rate for Payer: Cash Price |
$41.96
|
| Rate for Payer: Cigna Commercial |
$69.65
|
| Rate for Payer: First Health Commercial |
$79.72
|
| Rate for Payer: Humana Commercial |
$71.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.85
|
| Rate for Payer: Ohio Health Group HMO |
$62.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.90
|
| Rate for Payer: PHCS Commercial |
$80.56
|
| Rate for Payer: United Healthcare All Payer |
$73.85
|
|
|
VRAYLAR 1.5MG CAPSULE
|
Facility
|
OP
|
$83.92
|
|
|
Service Code
|
NDC 61874011511
|
| Hospital Charge Code |
25003588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.18 |
| Max. Negotiated Rate |
$80.56 |
| Rate for Payer: Aetna Commercial |
$64.62
|
| Rate for Payer: Anthem Medicaid |
$28.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.46
|
| Rate for Payer: Cash Price |
$41.96
|
| Rate for Payer: Cigna Commercial |
$69.65
|
| Rate for Payer: First Health Commercial |
$79.72
|
| Rate for Payer: Humana Commercial |
$71.33
|
| Rate for Payer: Humana KY Medicaid |
$28.86
|
| Rate for Payer: Kentucky WC Medicaid |
$29.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.85
|
| Rate for Payer: Ohio Health Group HMO |
$62.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.90
|
| Rate for Payer: PHCS Commercial |
$80.56
|
| Rate for Payer: United Healthcare All Payer |
$73.85
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Professional
|
Both
|
$1,550.00
|
|
|
Service Code
|
HCPCS 56620
|
| Hospital Charge Code |
76102162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.28 |
| Max. Negotiated Rate |
$930.00 |
| Rate for Payer: Aetna Commercial |
$742.08
|
| Rate for Payer: Ambetter Exchange |
$549.45
|
| Rate for Payer: Anthem Medicaid |
$403.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$549.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$549.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$659.34
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$778.07
|
| Rate for Payer: Healthspan PPO |
$718.52
|
| Rate for Payer: Humana Medicaid |
$403.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$645.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$549.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$411.35
|
| Rate for Payer: Molina Healthcare Passport |
$403.28
|
| Rate for Payer: Multiplan PHCS |
$930.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$714.28
|
| Rate for Payer: UHCCP Medicaid |
$542.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$407.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$549.45
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
OP
|
$1,550.00
|
|
|
Service Code
|
HCPCS 56620
|
| Hospital Charge Code |
76102162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$533.04 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Aetna Commercial |
$1,193.50
|
| Rate for Payer: Anthem Medicaid |
$533.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,209.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$1,286.50
|
| Rate for Payer: First Health Commercial |
$1,472.50
|
| Rate for Payer: Humana Commercial |
$1,317.50
|
| Rate for Payer: Humana KY Medicaid |
$533.04
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$538.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,271.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,143.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$543.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,364.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,162.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,348.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,069.50
|
| Rate for Payer: PHCS Commercial |
$1,488.00
|
| Rate for Payer: United Healthcare All Payer |
$1,364.00
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
IP
|
$1,550.00
|
|
|
Service Code
|
HCPCS 56620
|
| Hospital Charge Code |
76102162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$465.00 |
| Max. Negotiated Rate |
$1,488.00 |
| Rate for Payer: Aetna Commercial |
$1,193.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,209.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$1,286.50
|
| Rate for Payer: First Health Commercial |
$1,472.50
|
| Rate for Payer: Humana Commercial |
$1,317.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,271.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,143.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$465.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,364.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,162.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,348.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,069.50
|
| Rate for Payer: PHCS Commercial |
$1,488.00
|
| Rate for Payer: United Healthcare All Payer |
$1,364.00
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
OP
|
$4,112.95
|
|
|
Service Code
|
CPT 56620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,937.82 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
OP
|
$4,112.95
|
|
|
Service Code
|
CPT 56620
|
| Hospital Charge Code |
76102162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,937.82 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
|
|
VULVECTOMY SIMPLE; PARTIAL(P
|
Professional
|
Both
|
$1,550.00
|
|
|
Service Code
|
HCPCS 56620
|
| Hospital Charge Code |
761P2162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.28 |
| Max. Negotiated Rate |
$930.00 |
| Rate for Payer: Aetna Commercial |
$742.08
|
| Rate for Payer: Ambetter Exchange |
$549.45
|
| Rate for Payer: Anthem Medicaid |
$403.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$549.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$549.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$659.34
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$778.07
|
| Rate for Payer: Healthspan PPO |
$718.52
|
| Rate for Payer: Humana Medicaid |
$403.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$645.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$549.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$411.35
|
| Rate for Payer: Molina Healthcare Passport |
$403.28
|
| Rate for Payer: Multiplan PHCS |
$930.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$714.28
|
| Rate for Payer: UHCCP Medicaid |
$542.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$407.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$549.45
|
|
