|
LEVEL 2 IMAG W/O CON UROLOGY(T
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
402T0053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem Medicaid |
$264.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$384.00
|
| 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: Humana KY Medicaid |
$264.12
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$266.80
|
| 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 |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.41
|
| 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
|
|
|
LEVEL2 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
HCPCS 88302
|
| Hospital Charge Code |
30001503
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$29.90 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$184.69
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.30
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
LEVEL2 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
HCPCS 88302
|
| Hospital Charge Code |
30001503
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$25.75 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem Medicaid |
$79.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$184.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.76
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Humana KY Medicaid |
$79.10
|
| Rate for Payer: Humana Medicare Advantage |
$25.75
|
| Rate for Payer: Kentucky WC Medicaid |
$79.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.30
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
LEVEL2 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 88302
|
| Hospital Charge Code |
30001503
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$230.00 |
| Rate for Payer: Aetna Commercial |
$72.79
|
| Rate for Payer: Anthem Medicaid |
$34.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$230.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$30.19
|
| Rate for Payer: Healthspan PPO |
$69.11
|
| Rate for Payer: Humana Medicaid |
$34.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.18
|
| Rate for Payer: Molina Healthcare Passport |
$34.49
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.00
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$34.83
|
|
|
LEVEL3 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS 88304
|
| Hospital Charge Code |
30001504
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$92.45
|
| Rate for Payer: Anthem Medicaid |
$43.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$252.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$38.71
|
| Rate for Payer: Healthspan PPO |
$87.78
|
| Rate for Payer: Humana Medicaid |
$43.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.58
|
| Rate for Payer: Molina Healthcare Passport |
$43.71
|
| Rate for Payer: Multiplan PHCS |
$151.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$176.40
|
| Rate for Payer: UHCCP Medicaid |
$88.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.15
|
|
|
LEVEL3 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS 88304
|
| Hospital Charge Code |
30001504
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna Commercial |
$194.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.36
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$209.16
|
| Rate for Payer: First Health Commercial |
$239.40
|
| Rate for Payer: Humana Commercial |
$214.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.76
|
| Rate for Payer: Ohio Health Group HMO |
$189.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.12
|
| Rate for Payer: PHCS Commercial |
$241.92
|
| Rate for Payer: United Healthcare All Payer |
$221.76
|
|
|
LEVEL3 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS 88304
|
| Hospital Charge Code |
30001504
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna Commercial |
$194.04
|
| Rate for Payer: Anthem Medicaid |
$86.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.26
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$209.16
|
| Rate for Payer: First Health Commercial |
$239.40
|
| Rate for Payer: Humana Commercial |
$214.20
|
| Rate for Payer: Humana KY Medicaid |
$86.66
|
| Rate for Payer: Humana Medicare Advantage |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$87.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.76
|
| Rate for Payer: Ohio Health Group HMO |
$189.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.12
|
| Rate for Payer: PHCS Commercial |
$241.92
|
| Rate for Payer: United Healthcare All Payer |
$221.76
|
|
|
LEVEL4 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
HCPCS 88305
|
| Hospital Charge Code |
30001507
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$34.71 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: Aetna Commercial |
$205.59
|
| Rate for Payer: Anthem Medicaid |
$91.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.26
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$221.61
|
| Rate for Payer: First Health Commercial |
$253.65
|
| Rate for Payer: Humana Commercial |
$226.95
|
| Rate for Payer: Humana KY Medicaid |
$91.82
|
| Rate for Payer: Humana Medicare Advantage |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$92.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$234.96
|
| Rate for Payer: Ohio Health Group HMO |
$200.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.77
|
| Rate for Payer: PHCS Commercial |
$256.32
|
| Rate for Payer: United Healthcare All Payer |
$234.96
|
|
|
LEVEL4 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
HCPCS 88305
|
| Hospital Charge Code |
30001507
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$34.71 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: Aetna Commercial |
$205.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.40
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$221.61
|
| Rate for Payer: First Health Commercial |
$253.65
|
| Rate for Payer: Humana Commercial |
$226.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$234.96
|
| Rate for Payer: Ohio Health Group HMO |
$200.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.77
|
| Rate for Payer: PHCS Commercial |
$256.32
|
| Rate for Payer: United Healthcare All Payer |
$234.96
|
|
|
LEVEL4 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$267.00
|
|
|
Service Code
|
HCPCS 88305
|
| Hospital Charge Code |
30001507
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$267.00 |
| Rate for Payer: Aetna Commercial |
$158.53
|
| Rate for Payer: Anthem Medicaid |
$61.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$267.00
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$66.15
|
| Rate for Payer: Healthspan PPO |
$150.53
|
| Rate for Payer: Humana Medicaid |
$61.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.05
|
| Rate for Payer: Molina Healthcare Passport |
$61.81
|
| Rate for Payer: Multiplan PHCS |
$160.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.90
|
| Rate for Payer: UHCCP Medicaid |
$93.45
|
| Rate for Payer: United Healthcare Non-Options |
$35.65
|
| Rate for Payer: United Healthcare Options |
$35.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$62.43
|
|
|
LEVEL5 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS 88309
|
| Hospital Charge Code |
30001509
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$1,041.03 |
| Rate for Payer: Aetna Commercial |
$431.97
|
| Rate for Payer: Anthem Medicaid |
$192.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$743.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,041.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,003.85
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$465.63
|
| Rate for Payer: First Health Commercial |
$532.95
|
| Rate for Payer: Humana Commercial |
$476.85
|
| Rate for Payer: Humana KY Medicaid |
$192.93
|
| Rate for Payer: Humana Medicare Advantage |
$743.59
|
| Rate for Payer: Kentucky WC Medicaid |
$194.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$460.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$414.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$493.68
|
| Rate for Payer: Ohio Health Group HMO |
$420.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.91
|
| Rate for Payer: PHCS Commercial |
$538.56
|
| Rate for Payer: United Healthcare All Payer |
$493.68
|
|
|
LEVEL5 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
HCPCS 88309
|
| Hospital Charge Code |
30001509
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$74.35 |
| Max. Negotiated Rate |
$561.00 |
| Rate for Payer: Aetna Commercial |
$477.76
|
| Rate for Payer: Anthem Medicaid |
$232.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$561.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$184.67
|
| Rate for Payer: Healthspan PPO |
$453.64
|
| Rate for Payer: Humana Medicaid |
$232.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$74.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$237.24
|
| Rate for Payer: Molina Healthcare Passport |
$232.59
|
| Rate for Payer: Multiplan PHCS |
$336.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$392.70
|
| Rate for Payer: UHCCP Medicaid |
$196.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$234.92
|
|
|
LEVEL5 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS 88309
|
| Hospital Charge Code |
30001509
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$538.56 |
| Rate for Payer: Aetna Commercial |
$431.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.48
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$465.63
|
| Rate for Payer: First Health Commercial |
$532.95
|
| Rate for Payer: Humana Commercial |
$476.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$460.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$414.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$493.68
|
| Rate for Payer: Ohio Health Group HMO |
$420.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.91
|
| Rate for Payer: PHCS Commercial |
$538.56
|
| Rate for Payer: United Healthcare All Payer |
$493.68
|
|
|
LEVEMIR FLX PEN 100 U/ML 3mL
|
Facility
|
OP
|
$63.29
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$60.76 |
| Rate for Payer: Aetna Commercial |
$48.73
|
| Rate for Payer: Anthem Medicaid |
$21.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.37
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cigna Commercial |
$52.53
|
| Rate for Payer: First Health Commercial |
$60.13
|
| Rate for Payer: Humana Commercial |
$53.80
|
| Rate for Payer: Humana KY Medicaid |
$21.77
|
| Rate for Payer: Kentucky WC Medicaid |
$21.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.70
|
| Rate for Payer: Ohio Health Group HMO |
$47.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.62
|
| Rate for Payer: PHCS Commercial |
$60.76
|
| Rate for Payer: United Healthcare All Payer |
$55.70
|
|
|
LEVEMIR FLX PEN 100 U/ML 3mL
|
Facility
|
IP
|
$63.29
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$60.76 |
| Rate for Payer: Aetna Commercial |
$48.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.37
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cigna Commercial |
$52.53
|
| Rate for Payer: First Health Commercial |
$60.13
|
| Rate for Payer: Humana Commercial |
$53.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.70
|
| Rate for Payer: Ohio Health Group HMO |
$47.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.62
|
| Rate for Payer: PHCS Commercial |
$60.76
|
| Rate for Payer: United Healthcare All Payer |
$55.70
|
|
|
LEVETIRACETAM 10mg(250mg/50mL)
|
Facility
|
OP
|
$42.29
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna Commercial |
$32.56
|
| Rate for Payer: Anthem Medicaid |
$14.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.99
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: Cigna Commercial |
$35.10
|
| Rate for Payer: First Health Commercial |
$40.18
|
| Rate for Payer: Humana Commercial |
$35.95
|
| Rate for Payer: Humana KY Medicaid |
$14.54
|
| Rate for Payer: Kentucky WC Medicaid |
$14.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.22
|
| Rate for Payer: Ohio Health Group HMO |
$31.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.11
|
| Rate for Payer: PHCS Commercial |
$40.60
|
| Rate for Payer: United Healthcare All Payer |
$37.22
|
|
|
LEVETIRACETAM 10mg(250mg/50mL)
|
Facility
|
IP
|
$42.29
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna Commercial |
$32.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.99
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: Cigna Commercial |
$35.10
|
| Rate for Payer: First Health Commercial |
$40.18
|
| Rate for Payer: Humana Commercial |
$35.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.22
|
| Rate for Payer: Ohio Health Group HMO |
$31.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.11
|
| Rate for Payer: PHCS Commercial |
$40.60
|
| Rate for Payer: United Healthcare All Payer |
$37.22
|
|
|
LEVETIRACETAM 10mg(500mg100mL)
|
Facility
|
IP
|
$100.83
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$96.80 |
| Rate for Payer: Aetna Commercial |
$77.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.65
|
| Rate for Payer: Cash Price |
$50.42
|
| Rate for Payer: Cigna Commercial |
$83.69
|
| Rate for Payer: First Health Commercial |
$95.79
|
| Rate for Payer: Humana Commercial |
$85.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.73
|
| Rate for Payer: Ohio Health Group HMO |
$75.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.26
|
| Rate for Payer: PHCS Commercial |
$96.80
|
| Rate for Payer: United Healthcare All Payer |
$88.73
|
|
|
LEVETIRACETAM 10mg(500mg100mL)
|
Facility
|
OP
|
$100.83
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$96.80 |
| Rate for Payer: Aetna Commercial |
$77.64
|
| Rate for Payer: Anthem Medicaid |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.65
|
| Rate for Payer: Cash Price |
$50.42
|
| Rate for Payer: Cigna Commercial |
$83.69
|
| Rate for Payer: First Health Commercial |
$95.79
|
| Rate for Payer: Humana Commercial |
$85.71
|
| Rate for Payer: Humana KY Medicaid |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$35.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.73
|
| Rate for Payer: Ohio Health Group HMO |
$75.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.26
|
| Rate for Payer: PHCS Commercial |
$96.80
|
| Rate for Payer: United Healthcare All Payer |
$88.73
|
|
|
LEVISIN(HYSCYAM)0.125MG/5MLELX
|
Facility
|
IP
|
$9.11
|
|
|
Service Code
|
NDC 39328004816
|
| Hospital Charge Code |
25000861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
LEVISIN(HYSCYAM)0.125MG/5MLELX
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 39328004816
|
| Hospital Charge Code |
25000861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
LEVOCARNITINE 1 GM/5 ML VIAL
|
Facility
|
OP
|
$193.95
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
25003162
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.21 |
| Max. Negotiated Rate |
$186.19 |
| Rate for Payer: Aetna Commercial |
$149.34
|
| Rate for Payer: Anthem Medicaid |
$66.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$151.28
|
| Rate for Payer: Cash Price |
$96.97
|
| Rate for Payer: Cigna Commercial |
$160.98
|
| Rate for Payer: First Health Commercial |
$184.25
|
| Rate for Payer: Humana Commercial |
$164.86
|
| Rate for Payer: Humana KY Medicaid |
$66.70
|
| Rate for Payer: Kentucky WC Medicaid |
$67.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$170.68
|
| Rate for Payer: Ohio Health Group HMO |
$145.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.12
|
| Rate for Payer: PHCS Commercial |
$186.19
|
| Rate for Payer: United Healthcare All Payer |
$170.68
|
|
|
LEVOCARNITINE 1 GM/5 ML VIAL
|
Facility
|
IP
|
$193.95
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
25003162
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.21 |
| Max. Negotiated Rate |
$186.19 |
| Rate for Payer: Aetna Commercial |
$149.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$151.28
|
| Rate for Payer: Cash Price |
$96.97
|
| Rate for Payer: Cigna Commercial |
$160.98
|
| Rate for Payer: First Health Commercial |
$184.25
|
| Rate for Payer: Humana Commercial |
$164.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$170.68
|
| Rate for Payer: Ohio Health Group HMO |
$145.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.12
|
| Rate for Payer: PHCS Commercial |
$186.19
|
| Rate for Payer: United Healthcare All Payer |
$170.68
|
|
|
LEVOPHED (NOREPINEPHRI 4MG/4ML
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
NDC 781375575
|
| Hospital Charge Code |
25003163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.28 |
| Max. Negotiated Rate |
$112.80 |
| Rate for Payer: Aetna Commercial |
$90.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.65
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: First Health Commercial |
$111.62
|
| Rate for Payer: Humana Commercial |
$99.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.40
|
| Rate for Payer: Ohio Health Group HMO |
$88.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.42
|
| Rate for Payer: PHCS Commercial |
$112.80
|
| Rate for Payer: United Healthcare All Payer |
$103.40
|
|
|
LEVOPHED (NOREPINEPHRI 4MG/4ML
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
NDC 781375575
|
| Hospital Charge Code |
25003163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.28 |
| Max. Negotiated Rate |
$112.80 |
| Rate for Payer: Aetna Commercial |
$90.48
|
| Rate for Payer: Anthem Medicaid |
$40.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.65
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: First Health Commercial |
$111.62
|
| Rate for Payer: Humana Commercial |
$99.88
|
| Rate for Payer: Humana KY Medicaid |
$40.41
|
| Rate for Payer: Kentucky WC Medicaid |
$40.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.40
|
| Rate for Payer: Ohio Health Group HMO |
$88.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.42
|
| Rate for Payer: PHCS Commercial |
$112.80
|
| Rate for Payer: United Healthcare All Payer |
$103.40
|
|
