|
LIDOCAINE 2% JELLY W/INJ 6ML
|
Facility
|
IP
|
$22.95
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
25003169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna Commercial |
$17.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.90
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cigna Commercial |
$19.05
|
| Rate for Payer: First Health Commercial |
$21.80
|
| Rate for Payer: Humana Commercial |
$19.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.20
|
| Rate for Payer: Ohio Health Group HMO |
$17.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.11
|
| Rate for Payer: PHCS Commercial |
$22.03
|
| Rate for Payer: United Healthcare All Payer |
$20.20
|
|
|
LIDOCAINE 2% JELLY W/INJ 6ML
|
Facility
|
OP
|
$22.95
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
25003169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna Commercial |
$17.67
|
| Rate for Payer: Anthem Medicaid |
$7.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.90
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cigna Commercial |
$19.05
|
| Rate for Payer: First Health Commercial |
$21.80
|
| Rate for Payer: Humana Commercial |
$19.51
|
| Rate for Payer: Humana KY Medicaid |
$7.89
|
| Rate for Payer: Kentucky WC Medicaid |
$7.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.20
|
| Rate for Payer: Ohio Health Group HMO |
$17.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.11
|
| Rate for Payer: PHCS Commercial |
$22.03
|
| Rate for Payer: United Healthcare All Payer |
$20.20
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
OP
|
$78.34
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem Medicaid |
$26.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Humana KY Medicaid |
$26.94
|
| Rate for Payer: Kentucky WC Medicaid |
$27.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.29
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
IP
|
$75.12
|
|
| Hospital Charge Code |
636T0105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$72.12 |
| Rate for Payer: Aetna Commercial |
$57.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.59
|
| Rate for Payer: Cash Price |
$37.56
|
| Rate for Payer: Cigna Commercial |
$62.35
|
| Rate for Payer: First Health Commercial |
$71.36
|
| Rate for Payer: Humana Commercial |
$63.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.11
|
| Rate for Payer: Ohio Health Group HMO |
$56.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.29
|
| Rate for Payer: PHCS Commercial |
$72.12
|
| Rate for Payer: United Healthcare All Payer |
$66.11
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
IP
|
$78.34
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.29
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
OP
|
$75.12
|
|
| Hospital Charge Code |
636T0105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$72.12 |
| Rate for Payer: Aetna Commercial |
$57.84
|
| Rate for Payer: Anthem Medicaid |
$25.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.59
|
| Rate for Payer: Cash Price |
$37.56
|
| Rate for Payer: Cigna Commercial |
$62.35
|
| Rate for Payer: First Health Commercial |
$71.36
|
| Rate for Payer: Humana Commercial |
$63.85
|
| Rate for Payer: Humana KY Medicaid |
$25.83
|
| Rate for Payer: Kentucky WC Medicaid |
$26.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.11
|
| Rate for Payer: Ohio Health Group HMO |
$56.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.29
|
| Rate for Payer: PHCS Commercial |
$72.12
|
| Rate for Payer: United Healthcare All Payer |
$66.11
|
|
|
LIDOCAINE 2% MDV 20mL
|
Professional
|
Both
|
$75.12
|
|
| Hospital Charge Code |
63600105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.29 |
| Max. Negotiated Rate |
$75.12 |
| Rate for Payer: Buckeye Medicare Advantage |
$75.12
|
| Rate for Payer: Cash Price |
$37.56
|
| Rate for Payer: Multiplan PHCS |
$45.07
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.58
|
| Rate for Payer: UHCCP Medicaid |
$26.29
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
OP
|
$75.12
|
|
| Hospital Charge Code |
63600105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$72.12 |
| Rate for Payer: Aetna Commercial |
$57.84
|
| Rate for Payer: Anthem Medicaid |
$25.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.59
|
| Rate for Payer: Cash Price |
$37.56
|
| Rate for Payer: Cigna Commercial |
$62.35
|
| Rate for Payer: First Health Commercial |
$71.36
|
| Rate for Payer: Humana Commercial |
$63.85
|
| Rate for Payer: Humana KY Medicaid |
$25.83
|
| Rate for Payer: Kentucky WC Medicaid |
$26.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.11
|
| Rate for Payer: Ohio Health Group HMO |
$56.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.29
|
| Rate for Payer: PHCS Commercial |
$72.12
|
| Rate for Payer: United Healthcare All Payer |
$66.11
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
IP
|
$75.12
|
|
| Hospital Charge Code |
63600105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$72.12 |
| Rate for Payer: Aetna Commercial |
$57.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.59
|
| Rate for Payer: Cash Price |
$37.56
|
| Rate for Payer: Cigna Commercial |
$62.35
|
| Rate for Payer: First Health Commercial |
$71.36
|
| Rate for Payer: Humana Commercial |
$63.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.11
|
| Rate for Payer: Ohio Health Group HMO |
$56.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.29
|
| Rate for Payer: PHCS Commercial |
$72.12
|
| Rate for Payer: United Healthcare All Payer |
$66.11
|
|
|
LIDOCAINE 2% PF 2ML VIAL
|
Facility
|
OP
|
$78.93
|
|
|
Service Code
|
NDC 63323049527
|
| Hospital Charge Code |
25004085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$75.77 |
| Rate for Payer: Aetna Commercial |
$60.78
|
| Rate for Payer: Anthem Medicaid |
$27.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.57
|
| Rate for Payer: Cash Price |
$39.47
|
| Rate for Payer: Cigna Commercial |
$65.51
|
| Rate for Payer: First Health Commercial |
$74.98
|
| Rate for Payer: Humana Commercial |
$67.09
|
| Rate for Payer: Humana KY Medicaid |
$27.14
|
| Rate for Payer: Kentucky WC Medicaid |
$27.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.46
|
| Rate for Payer: Ohio Health Group HMO |
$59.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.47
|
| Rate for Payer: PHCS Commercial |
$75.77
|
| Rate for Payer: United Healthcare All Payer |
$69.46
|
|
|
LIDOCAINE 2% PF 2ML VIAL
|
Facility
|
IP
|
$78.93
|
|
|
Service Code
|
NDC 63323049527
|
| Hospital Charge Code |
25004085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$75.77 |
| Rate for Payer: Aetna Commercial |
$60.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.57
|
| Rate for Payer: Cash Price |
$39.47
|
| Rate for Payer: Cigna Commercial |
$65.51
|
| Rate for Payer: First Health Commercial |
$74.98
|
| Rate for Payer: Humana Commercial |
$67.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.46
|
| Rate for Payer: Ohio Health Group HMO |
$59.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.47
|
| Rate for Payer: PHCS Commercial |
$75.77
|
| Rate for Payer: United Healthcare All Payer |
$69.46
|
|
|
LIDOCAINE 2% VISCOUS 5ML
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
25003171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem Medicaid |
$9.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Humana KY Medicaid |
$9.63
|
| Rate for Payer: Kentucky WC Medicaid |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.68
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
LIDOCAINE 2% VISCOUS 5ML
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
25003171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.68
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
LIDOCAINE2%VISCOUS SOL'N(15ML)
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem Medicaid |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Humana KY Medicaid |
$3.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
LIDOCAINE2%VISCOUS SOL'N(15ML)
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
LIDOCAINE 3% 1 ML SWAB
|
Facility
|
OP
|
$10.50
|
|
|
Service Code
|
NDC 35781030105
|
| Hospital Charge Code |
25003969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Anthem Medicaid |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.19
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna Commercial |
$8.72
|
| Rate for Payer: First Health Commercial |
$9.98
|
| Rate for Payer: Humana Commercial |
$8.92
|
| Rate for Payer: Humana KY Medicaid |
$3.61
|
| Rate for Payer: Kentucky WC Medicaid |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$10.08
|
| Rate for Payer: United Healthcare All Payer |
$9.24
|
| Rate for Payer: Aetna Commercial |
$8.08
|
|
|
LIDOCAINE 3% 1 ML SWAB
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
NDC 35781030105
|
| Hospital Charge Code |
25003969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$8.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.19
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna Commercial |
$8.72
|
| Rate for Payer: First Health Commercial |
$9.98
|
| Rate for Payer: Humana Commercial |
$8.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$10.08
|
| Rate for Payer: United Healthcare All Payer |
$9.24
|
|
|
LIDOCAINE 4% 1 ML SPRAY
|
Facility
|
IP
|
$9.08
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
25003174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.72 |
| Rate for Payer: Aetna Commercial |
$6.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Cash Price |
$4.54
|
| Rate for Payer: Cigna Commercial |
$7.54
|
| Rate for Payer: First Health Commercial |
$8.63
|
| Rate for Payer: Humana Commercial |
$7.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.99
|
| Rate for Payer: Ohio Health Group HMO |
$6.81
|
| 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 |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Payer |
$7.99
|
|
|
LIDOCAINE 4% 1 ML SPRAY
|
Facility
|
OP
|
$9.08
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
25003174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.72 |
| Rate for Payer: Anthem Medicaid |
$3.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Cash Price |
$4.54
|
| Rate for Payer: Cigna Commercial |
$7.54
|
| Rate for Payer: First Health Commercial |
$8.63
|
| Rate for Payer: Humana Commercial |
$7.72
|
| Rate for Payer: Humana KY Medicaid |
$3.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.99
|
| Rate for Payer: Ohio Health Group HMO |
$6.81
|
| 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 |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Payer |
$7.99
|
| Rate for Payer: Aetna Commercial |
$6.99
|
|
|
LIDOCAINE 4% 5gm Crm KIT
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
25000604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.86
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.47
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
LIDOCAINE 4% 5gm Crm KIT
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
25000604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.86
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Humana KY Medicaid |
$12.72
|
| Rate for Payer: Kentucky WC Medicaid |
$12.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.47
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
Lidocaine 5% (30gm)
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
NDC 51672302002
|
| Hospital Charge Code |
25004098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem Medicaid |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Humana KY Medicaid |
$62.25
|
| Rate for Payer: Kentucky WC Medicaid |
$62.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.11
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
Lidocaine 5% (30gm)
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
NDC 51672302002
|
| Hospital Charge Code |
25004098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.11
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
LIDOCAINE+EPI 2%-1:200K PF 20
|
Facility
|
IP
|
$112.05
|
|
|
Service Code
|
NDC 409318301
|
| Hospital Charge Code |
25003943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.74
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
|
|
LIDOCAINE+EPI 2%-1:200K PF 20
|
Facility
|
OP
|
$112.05
|
|
|
Service Code
|
NDC 409318301
|
| Hospital Charge Code |
25003943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem Medicaid |
$38.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Humana KY Medicaid |
$38.53
|
| Rate for Payer: Kentucky WC Medicaid |
$38.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.74
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
