|
Labetalol 100mg/20mL(IV addit)
|
Facility
|
IP
|
$79.96
|
|
|
Service Code
|
NDC 409226720
|
| Hospital Charge Code |
25004044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.76 |
| Rate for Payer: Aetna Commercial |
$61.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.37
|
| Rate for Payer: Cash Price |
$39.98
|
| Rate for Payer: Cigna Commercial |
$66.37
|
| Rate for Payer: First Health Commercial |
$75.96
|
| Rate for Payer: Humana Commercial |
$67.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.17
|
| Rate for Payer: PHCS Commercial |
$76.76
|
| Rate for Payer: United Healthcare All Payer |
$70.36
|
|
|
LABETALOL 5mg (20mg SDV)
|
Facility
|
OP
|
$80.22
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
25004306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$77.01 |
| Rate for Payer: Aetna Commercial |
$61.77
|
| Rate for Payer: Anthem Medicaid |
$27.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.57
|
| Rate for Payer: Cash Price |
$40.11
|
| Rate for Payer: Cigna Commercial |
$66.58
|
| Rate for Payer: First Health Commercial |
$76.21
|
| Rate for Payer: Humana Commercial |
$68.19
|
| Rate for Payer: Humana KY Medicaid |
$27.59
|
| Rate for Payer: Kentucky WC Medicaid |
$27.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.59
|
| Rate for Payer: Ohio Health Group HMO |
$60.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.35
|
| Rate for Payer: PHCS Commercial |
$77.01
|
| Rate for Payer: United Healthcare All Payer |
$70.59
|
|
|
LABETALOL 5mg (20mg SDV)
|
Facility
|
IP
|
$80.22
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
25004306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$77.01 |
| Rate for Payer: Aetna Commercial |
$61.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.57
|
| Rate for Payer: Cash Price |
$40.11
|
| Rate for Payer: Cigna Commercial |
$66.58
|
| Rate for Payer: First Health Commercial |
$76.21
|
| Rate for Payer: Humana Commercial |
$68.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.59
|
| Rate for Payer: Ohio Health Group HMO |
$60.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.35
|
| Rate for Payer: PHCS Commercial |
$77.01
|
| Rate for Payer: United Healthcare All Payer |
$70.59
|
|
|
LABOR PER HOUR STAGE 1
|
Facility
|
OP
|
$124.00
|
|
| Hospital Charge Code |
72000003
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$42.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.72
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Humana KY Medicaid |
$42.64
|
| Rate for Payer: Kentucky WC Medicaid |
$43.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
LABOR PER HOUR STAGE 1
|
Facility
|
IP
|
$124.00
|
|
| Hospital Charge Code |
72000003
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.72
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
LABYRINTHOTOMY W/OR W/O CRYOSU
|
Facility
|
IP
|
$4,533.00
|
|
|
Service Code
|
HCPCS 69801
|
| Hospital Charge Code |
76102437
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,359.90 |
| Max. Negotiated Rate |
$4,351.68 |
| Rate for Payer: Aetna Commercial |
$3,490.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,535.74
|
| Rate for Payer: Cash Price |
$2,266.50
|
| Rate for Payer: Cigna Commercial |
$3,762.39
|
| Rate for Payer: First Health Commercial |
$4,306.35
|
| Rate for Payer: Humana Commercial |
$3,853.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,717.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,345.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,359.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,989.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,399.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,626.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,943.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,127.77
|
| Rate for Payer: PHCS Commercial |
$4,351.68
|
| Rate for Payer: United Healthcare All Payer |
$3,989.04
|
|
|
LABYRINTHOTOMY W/OR W/O CRYOSU
|
Professional
|
Both
|
$4,533.00
|
|
|
Service Code
|
HCPCS 69801
|
| Hospital Charge Code |
76102437
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.26 |
| Max. Negotiated Rate |
$2,719.80 |
| Rate for Payer: Aetna Commercial |
$1,061.07
|
| Rate for Payer: Ambetter Exchange |
$117.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$101.26
|
| Rate for Payer: Anthem Medicaid |
$566.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$117.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$117.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$141.10
|
| Rate for Payer: Cash Price |
$2,266.50
|
| Rate for Payer: Cash Price |
$2,266.50
|
| Rate for Payer: Cigna Commercial |
$1,035.79
|
| Rate for Payer: Healthspan PPO |
$941.22
|
| Rate for Payer: Humana Medicaid |
$566.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$378.35
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$117.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$577.45
|
| Rate for Payer: Molina Healthcare Passport |
$566.13
|
| Rate for Payer: Multiplan PHCS |
$2,719.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$152.85
|
| Rate for Payer: UHCCP Medicaid |
$106.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$571.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$117.58
|
|
|
LABYRINTHOTOMY W/OR W/O CRYOSU
|
Facility
|
OP
|
$1,933.00
|
|
|
Service Code
|
HCPCS 69801
|
| Hospital Charge Code |
761T2437
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$664.76 |
| Max. Negotiated Rate |
$1,916.14 |
| Rate for Payer: Aetna Commercial |
$1,488.41
|
| Rate for Payer: Anthem Medicaid |
$664.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,507.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$966.50
|
| Rate for Payer: Cash Price |
$966.50
|
| Rate for Payer: Cigna Commercial |
$1,604.39
|
| Rate for Payer: First Health Commercial |
$1,836.35
|
| Rate for Payer: Humana Commercial |
$1,643.05
|
| Rate for Payer: Humana KY Medicaid |
$664.76
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$671.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,585.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,426.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,701.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,449.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,546.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,681.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.77
|
| Rate for Payer: PHCS Commercial |
$1,855.68
|
| Rate for Payer: United Healthcare All Payer |
$1,701.04
|
|
|
LABYRINTHOTOMY W/OR W/O CRYOSU
|
Facility
|
IP
|
$1,933.00
|
|
|
Service Code
|
HCPCS 69801
|
| Hospital Charge Code |
761T2437
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$579.90 |
| Max. Negotiated Rate |
$1,855.68 |
| Rate for Payer: Aetna Commercial |
$1,488.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,507.74
|
| Rate for Payer: Cash Price |
$966.50
|
| Rate for Payer: Cigna Commercial |
$1,604.39
|
| Rate for Payer: First Health Commercial |
$1,836.35
|
| Rate for Payer: Humana Commercial |
$1,643.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,585.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,426.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,701.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,449.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,546.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,681.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.77
|
| Rate for Payer: PHCS Commercial |
$1,855.68
|
| Rate for Payer: United Healthcare All Payer |
$1,701.04
|
|
|
LABYRINTHOTOMY W/OR W/O CRYOSU
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 69801
|
| Hospital Charge Code |
761P2437
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.26 |
| Max. Negotiated Rate |
$1,560.00 |
| Rate for Payer: Aetna Commercial |
$1,061.07
|
| Rate for Payer: Ambetter Exchange |
$117.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$101.26
|
| Rate for Payer: Anthem Medicaid |
$566.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$117.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$117.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$141.10
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$1,035.79
|
| Rate for Payer: Healthspan PPO |
$941.22
|
| Rate for Payer: Humana Medicaid |
$566.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$378.35
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$117.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$577.45
|
| Rate for Payer: Molina Healthcare Passport |
$566.13
|
| Rate for Payer: Multiplan PHCS |
$1,560.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$152.85
|
| Rate for Payer: UHCCP Medicaid |
$106.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$571.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$117.58
|
|
|
LABYRINTHOTOMY W/OR W/O CRYOSU
|
Facility
|
OP
|
$4,533.00
|
|
|
Service Code
|
HCPCS 69801
|
| Hospital Charge Code |
76102437
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,368.67 |
| Max. Negotiated Rate |
$4,351.68 |
| Rate for Payer: Aetna Commercial |
$3,490.41
|
| Rate for Payer: Anthem Medicaid |
$1,558.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,535.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$2,266.50
|
| Rate for Payer: Cash Price |
$2,266.50
|
| Rate for Payer: Cigna Commercial |
$3,762.39
|
| Rate for Payer: First Health Commercial |
$4,306.35
|
| Rate for Payer: Humana Commercial |
$3,853.05
|
| Rate for Payer: Humana KY Medicaid |
$1,558.90
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,574.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,717.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,345.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,590.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,989.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,399.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,626.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,943.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,127.77
|
| Rate for Payer: PHCS Commercial |
$4,351.68
|
| Rate for Payer: United Healthcare All Payer |
$3,989.04
|
|
|
LAC-HYDRIN(AMMONIUM LACT 225GM
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 904598426
|
| Hospital Charge Code |
25000827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Anthem Medicaid |
$0.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.37
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna Commercial |
$1.46
|
| Rate for Payer: First Health Commercial |
$1.67
|
| Rate for Payer: Humana Commercial |
$1.50
|
| Rate for Payer: Humana KY Medicaid |
$0.61
|
| Rate for Payer: Kentucky WC Medicaid |
$0.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.55
|
| Rate for Payer: Ohio Health Group HMO |
$1.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.21
|
| Rate for Payer: PHCS Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Payer |
$1.55
|
|
|
LAC-HYDRIN(AMMONIUM LACT 225GM
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 904598426
|
| Hospital Charge Code |
25000827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.37
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna Commercial |
$1.46
|
| Rate for Payer: First Health Commercial |
$1.67
|
| Rate for Payer: Humana Commercial |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.55
|
| Rate for Payer: Ohio Health Group HMO |
$1.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.21
|
| Rate for Payer: PHCS Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Payer |
$1.55
|
|
|
LACOSAMIDE 50mg/5mL ORAL SOL'N
|
Facility
|
IP
|
$62.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$59.74 |
| Rate for Payer: Aetna Commercial |
$47.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.54
|
| Rate for Payer: Cash Price |
$31.11
|
| Rate for Payer: Cigna Commercial |
$51.65
|
| Rate for Payer: First Health Commercial |
$59.12
|
| Rate for Payer: Humana Commercial |
$52.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.76
|
| Rate for Payer: Ohio Health Group HMO |
$46.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.94
|
| Rate for Payer: PHCS Commercial |
$59.74
|
| Rate for Payer: United Healthcare All Payer |
$54.76
|
|
|
LACOSAMIDE 50mg/5mL ORAL SOL'N
|
Facility
|
OP
|
$62.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$59.74 |
| Rate for Payer: Aetna Commercial |
$47.92
|
| Rate for Payer: Anthem Medicaid |
$21.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.54
|
| Rate for Payer: Cash Price |
$31.11
|
| Rate for Payer: Cigna Commercial |
$51.65
|
| Rate for Payer: First Health Commercial |
$59.12
|
| Rate for Payer: Humana Commercial |
$52.90
|
| Rate for Payer: Humana KY Medicaid |
$21.40
|
| Rate for Payer: Kentucky WC Medicaid |
$21.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.76
|
| Rate for Payer: Ohio Health Group HMO |
$46.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.94
|
| Rate for Payer: PHCS Commercial |
$59.74
|
| Rate for Payer: United Healthcare All Payer |
$54.76
|
|
|
LACOSAMIDE 50MG TABLET
|
Facility
|
OP
|
$60.11
|
|
|
Service Code
|
NDC 31722081260
|
| Hospital Charge Code |
25000828
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem Medicaid |
$20.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.89
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cigna Commercial |
$49.89
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Humana KY Medicaid |
$20.67
|
| Rate for Payer: Kentucky WC Medicaid |
$20.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.90
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.48
|
| Rate for Payer: PHCS Commercial |
$57.71
|
| Rate for Payer: United Healthcare All Payer |
$52.90
|
|
|
LACOSAMIDE 50MG TABLET
|
Facility
|
IP
|
$60.11
|
|
|
Service Code
|
NDC 31722081260
|
| Hospital Charge Code |
25000828
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.89
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cigna Commercial |
$49.89
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.90
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.48
|
| Rate for Payer: PHCS Commercial |
$57.71
|
| Rate for Payer: United Healthcare All Payer |
$52.90
|
|
|
LACTAID ULTRA (LACTASE) TAB
|
Facility
|
IP
|
$4.98
|
|
|
Service Code
|
NDC 77333043550
|
| Hospital Charge Code |
25000829
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.73
|
| Rate for Payer: Humana Commercial |
$4.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
LACTAID ULTRA (LACTASE) TAB
|
Facility
|
OP
|
$4.98
|
|
|
Service Code
|
NDC 77333043550
|
| Hospital Charge Code |
25000829
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem Medicaid |
$1.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.73
|
| Rate for Payer: Humana Commercial |
$4.23
|
| Rate for Payer: Humana KY Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
LACTATED RINGERS 1000 ML
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
25003153
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
LACTATED RINGERS 1000 ML
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
25003153
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
LACTATED RINGERS (FS) 1000ML
|
Facility
|
IP
|
$94.80
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
25003153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.44 |
| Max. Negotiated Rate |
$91.01 |
| Rate for Payer: Aetna Commercial |
$73.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.94
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$78.68
|
| Rate for Payer: First Health Commercial |
$90.06
|
| Rate for Payer: Humana Commercial |
$80.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.42
|
| Rate for Payer: Ohio Health Group HMO |
$71.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.41
|
| Rate for Payer: PHCS Commercial |
$91.01
|
| Rate for Payer: United Healthcare All Payer |
$83.42
|
|
|
LACTATED RINGERS (FS) 1000ML
|
Facility
|
OP
|
$94.80
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
25003153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.44 |
| Max. Negotiated Rate |
$91.01 |
| Rate for Payer: Aetna Commercial |
$73.00
|
| Rate for Payer: Anthem Medicaid |
$32.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.94
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$78.68
|
| Rate for Payer: First Health Commercial |
$90.06
|
| Rate for Payer: Humana Commercial |
$80.58
|
| Rate for Payer: Humana KY Medicaid |
$32.60
|
| Rate for Payer: Kentucky WC Medicaid |
$32.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.42
|
| Rate for Payer: Ohio Health Group HMO |
$71.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.41
|
| Rate for Payer: PHCS Commercial |
$91.01
|
| Rate for Payer: United Healthcare All Payer |
$83.42
|
|
|
LACTATED RINGERS (FS) 500ML
|
Facility
|
OP
|
$112.83
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
25003152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$108.32 |
| Rate for Payer: Aetna Commercial |
$86.88
|
| Rate for Payer: Anthem Medicaid |
$38.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.01
|
| Rate for Payer: Cash Price |
$56.42
|
| Rate for Payer: Cigna Commercial |
$93.65
|
| Rate for Payer: First Health Commercial |
$107.19
|
| Rate for Payer: Humana Commercial |
$95.91
|
| Rate for Payer: Humana KY Medicaid |
$38.80
|
| Rate for Payer: Kentucky WC Medicaid |
$39.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.29
|
| Rate for Payer: Ohio Health Group HMO |
$84.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.85
|
| Rate for Payer: PHCS Commercial |
$108.32
|
| Rate for Payer: United Healthcare All Payer |
$99.29
|
|
|
LACTATED RINGERS (FS) 500ML
|
Facility
|
IP
|
$112.83
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
25003152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$108.32 |
| Rate for Payer: Aetna Commercial |
$86.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.01
|
| Rate for Payer: Cash Price |
$56.42
|
| Rate for Payer: Cigna Commercial |
$93.65
|
| Rate for Payer: First Health Commercial |
$107.19
|
| Rate for Payer: Humana Commercial |
$95.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.29
|
| Rate for Payer: Ohio Health Group HMO |
$84.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.85
|
| Rate for Payer: PHCS Commercial |
$108.32
|
| Rate for Payer: United Healthcare All Payer |
$99.29
|
|
