|
LEUCOVORIN CALCIUM 50MG VIAL
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem Medicaid |
$40.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Humana KY Medicaid |
$40.24
|
| Rate for Payer: Kentucky WC Medicaid |
$40.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.27
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
LEUCOVORIN CALCIUM 50MG VIAL
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.27
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
LEUCOVORIN CALCIUM 5MG TABLET
|
Facility
|
OP
|
$9.12
|
|
|
Service Code
|
NDC 54449613
|
| Hospital Charge Code |
25000854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Anthem Medicaid |
$3.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.57
|
| Rate for Payer: First Health Commercial |
$8.66
|
| Rate for Payer: Humana Commercial |
$7.75
|
| Rate for Payer: Humana KY Medicaid |
$3.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.83
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
LEUCOVORIN CALCIUM 5MG TABLET
|
Facility
|
IP
|
$9.12
|
|
|
Service Code
|
NDC 54449613
|
| Hospital Charge Code |
25000854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.57
|
| Rate for Payer: First Health Commercial |
$8.66
|
| Rate for Payer: Humana Commercial |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.83
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
LEUKOREDUCED PRC IRRADIATED
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS P9040
|
| Hospital Charge Code |
38000015
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$442.75
|
| Rate for Payer: Anthem Medicaid |
$197.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$229.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$320.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$309.35
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$477.25
|
| Rate for Payer: First Health Commercial |
$546.25
|
| Rate for Payer: Humana Commercial |
$488.75
|
| Rate for Payer: Humana KY Medicaid |
$197.74
|
| Rate for Payer: Humana Medicare Advantage |
$229.15
|
| Rate for Payer: Kentucky WC Medicaid |
$199.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$471.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$424.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$274.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$201.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$506.00
|
| Rate for Payer: Ohio Health Group HMO |
$431.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.25
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
LEUKOREDUCED PRC IRRADIATED
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS P9040
|
| Hospital Charge Code |
38000015
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$442.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$477.25
|
| Rate for Payer: First Health Commercial |
$546.25
|
| Rate for Payer: Humana Commercial |
$488.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$471.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$424.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$506.00
|
| Rate for Payer: Ohio Health Group HMO |
$431.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.25
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
LEVABID (HYOSCYAMINE)0.37 MG T
|
Facility
|
OP
|
$12.81
|
|
|
Service Code
|
NDC 68220011510
|
| Hospital Charge Code |
25000855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$12.30 |
| Rate for Payer: Aetna Commercial |
$9.86
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.99
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cigna Commercial |
$10.63
|
| Rate for Payer: First Health Commercial |
$12.17
|
| Rate for Payer: Humana Commercial |
$10.89
|
| Rate for Payer: Humana KY Medicaid |
$4.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.27
|
| Rate for Payer: Ohio Health Group HMO |
$9.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.97
|
| Rate for Payer: PHCS Commercial |
$12.30
|
| Rate for Payer: United Healthcare All Payer |
$11.27
|
|
|
LEVABID (HYOSCYAMINE)0.37 MG T
|
Facility
|
IP
|
$12.81
|
|
|
Service Code
|
NDC 68220011510
|
| Hospital Charge Code |
25000855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$12.30 |
| Rate for Payer: Aetna Commercial |
$9.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.99
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cigna Commercial |
$10.63
|
| Rate for Payer: First Health Commercial |
$12.17
|
| Rate for Payer: Humana Commercial |
$10.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.27
|
| Rate for Payer: Ohio Health Group HMO |
$9.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.97
|
| Rate for Payer: PHCS Commercial |
$12.30
|
| Rate for Payer: United Healthcare All Payer |
$11.27
|
|
|
LEVAQUIN (LEVOFLOX)250MG50ML
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem Medicaid |
$38.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Humana KY Medicaid |
$38.86
|
| Rate for Payer: Kentucky WC Medicaid |
$39.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.03
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
LEVAQUIN (LEVOFLOX)250MG50ML
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.03
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
LEVAQUIN (LEVOFLOX 500G/100ML)
|
Facility
|
OP
|
$113.12
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$108.60 |
| Rate for Payer: Aetna Commercial |
$87.10
|
| Rate for Payer: Anthem Medicaid |
$38.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.23
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cigna Commercial |
$93.89
|
| Rate for Payer: First Health Commercial |
$107.46
|
| Rate for Payer: Humana Commercial |
$96.15
|
| Rate for Payer: Humana KY Medicaid |
$38.90
|
| Rate for Payer: Kentucky WC Medicaid |
$39.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.55
|
| Rate for Payer: Ohio Health Group HMO |
$84.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.07
|
| Rate for Payer: PHCS Commercial |
$108.60
|
| Rate for Payer: United Healthcare All Payer |
$99.55
|
|
|
LEVAQUIN (LEVOFLOX 500G/100ML)
|
Facility
|
IP
|
$113.12
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$108.60 |
| Rate for Payer: Aetna Commercial |
$87.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.23
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cigna Commercial |
$93.89
|
| Rate for Payer: First Health Commercial |
$107.46
|
| Rate for Payer: Humana Commercial |
$96.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.55
|
| Rate for Payer: Ohio Health Group HMO |
$84.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.07
|
| Rate for Payer: PHCS Commercial |
$108.60
|
| Rate for Payer: United Healthcare All Payer |
$99.55
|
|
|
LEVAQUIN (LEVOFLOXACIN) 250 MG
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 65862053650
|
| Hospital Charge Code |
25000856
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
LEVAQUIN (LEVOFLOXACIN) 250 MG
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 65862053650
|
| Hospital Charge Code |
25000856
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
LEVAQUIN(LEVOFLOXACINE)750MG T
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 904635361
|
| Hospital Charge Code |
25000857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
LEVAQUIN(LEVOFLOXACINE)750MG T
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 904635361
|
| Hospital Charge Code |
25000857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
|
|
LEVAQUIN (LVFLXC)750MG/150ML
|
Facility
|
OP
|
$113.50
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$108.96 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Anthem Medicaid |
$39.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.53
|
| Rate for Payer: Cash Price |
$56.75
|
| Rate for Payer: Cigna Commercial |
$94.20
|
| Rate for Payer: First Health Commercial |
$107.82
|
| Rate for Payer: Humana Commercial |
$96.48
|
| Rate for Payer: Humana KY Medicaid |
$39.03
|
| Rate for Payer: Kentucky WC Medicaid |
$39.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.88
|
| Rate for Payer: Ohio Health Group HMO |
$85.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.18
|
| Rate for Payer: PHCS Commercial |
$108.96
|
| Rate for Payer: United Healthcare All Payer |
$99.88
|
|
|
LEVAQUIN (LVFLXC)750MG/150ML
|
Facility
|
IP
|
$113.50
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$108.96 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.53
|
| Rate for Payer: Cash Price |
$56.75
|
| Rate for Payer: Cigna Commercial |
$94.20
|
| Rate for Payer: First Health Commercial |
$107.82
|
| Rate for Payer: Humana Commercial |
$96.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.88
|
| Rate for Payer: Ohio Health Group HMO |
$85.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.18
|
| Rate for Payer: PHCS Commercial |
$108.96
|
| Rate for Payer: United Healthcare All Payer |
$99.88
|
|
|
LEVAQUIT(LEVAFLOXAC 500MG/1TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 68084048201
|
| Hospital Charge Code |
25000858
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
LEVAQUIT(LEVAFLOXAC 500MG/1TAB
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 68084048201
|
| Hospital Charge Code |
25000858
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY
|
Facility
|
OP
|
$918.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
40200053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$881.28 |
| Rate for Payer: Aetna Commercial |
$706.86
|
| Rate for Payer: Anthem Medicaid |
$315.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$716.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$761.94
|
| Rate for Payer: First Health Commercial |
$872.10
|
| Rate for Payer: Humana Commercial |
$780.30
|
| Rate for Payer: Humana KY Medicaid |
$315.70
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$318.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$752.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$677.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$322.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$807.84
|
| Rate for Payer: Ohio Health Group HMO |
$688.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$119.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.58
|
| Rate for Payer: PHCS Commercial |
$881.28
|
| Rate for Payer: United Healthcare All Payer |
$807.84
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY
|
Professional
|
Both
|
$918.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
40200053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$44.97 |
| Max. Negotiated Rate |
$918.00 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Anthem Medicaid |
$71.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$918.00
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$183.51
|
| Rate for Payer: Healthspan PPO |
$191.43
|
| Rate for Payer: Humana Medicaid |
$71.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.80
|
| Rate for Payer: Molina Healthcare Passport |
$71.37
|
| Rate for Payer: Multiplan PHCS |
$550.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$642.60
|
| Rate for Payer: UHCCP Medicaid |
$321.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.08
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY
|
Facility
|
IP
|
$918.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
40200053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$119.34 |
| Max. Negotiated Rate |
$881.28 |
| Rate for Payer: Aetna Commercial |
$706.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$716.04
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$761.94
|
| Rate for Payer: First Health Commercial |
$872.10
|
| Rate for Payer: Humana Commercial |
$780.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$752.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$677.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$275.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$807.84
|
| Rate for Payer: Ohio Health Group HMO |
$688.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$119.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.58
|
| Rate for Payer: PHCS Commercial |
$881.28
|
| Rate for Payer: United Healthcare All Payer |
$807.84
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
402P0053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$44.97 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Anthem Medicaid |
$71.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$183.51
|
| Rate for Payer: Healthspan PPO |
$191.43
|
| Rate for Payer: Humana Medicaid |
$71.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.80
|
| Rate for Payer: Molina Healthcare Passport |
$71.37
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.08
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY(T
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
402T0053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$99.84 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.08
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
