|
LENS ZCB00 DIOPTER +9.5 (S)
|
Facility
|
IP
|
$1,737.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
LENS ZCB00 DIOPTER +9.5 (S)
|
Facility
|
OP
|
$1,737.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem Medicaid |
$597.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Humana KY Medicaid |
$597.35
|
| Rate for Payer: Kentucky WC Medicaid |
$603.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
LEQVIO 1MG (284MG PFS)
|
Facility
|
OP
|
$18,801.08
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
25004189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$18,049.04 |
| Rate for Payer: Aetna Commercial |
$14,476.83
|
| Rate for Payer: Anthem Medicaid |
$6,465.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,664.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.67
|
| Rate for Payer: Cash Price |
$9,400.54
|
| Rate for Payer: Cash Price |
$9,400.54
|
| Rate for Payer: Cigna Commercial |
$15,604.90
|
| Rate for Payer: First Health Commercial |
$17,861.03
|
| Rate for Payer: Humana Commercial |
$15,980.92
|
| Rate for Payer: Humana KY Medicaid |
$6,465.69
|
| Rate for Payer: Humana Medicare Advantage |
$12.35
|
| Rate for Payer: Kentucky WC Medicaid |
$6,531.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,416.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,875.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,595.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,544.95
|
| Rate for Payer: Ohio Health Group HMO |
$14,100.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,040.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,356.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,972.75
|
| Rate for Payer: PHCS Commercial |
$18,049.04
|
| Rate for Payer: United Healthcare All Payer |
$16,544.95
|
|
|
LEQVIO 1MG (284MG PFS)
|
Facility
|
IP
|
$18,801.08
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
25004189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,640.32 |
| Max. Negotiated Rate |
$18,049.04 |
| Rate for Payer: Aetna Commercial |
$14,476.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,664.84
|
| Rate for Payer: Cash Price |
$9,400.54
|
| Rate for Payer: Cigna Commercial |
$15,604.90
|
| Rate for Payer: First Health Commercial |
$17,861.03
|
| Rate for Payer: Humana Commercial |
$15,980.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,416.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,875.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,640.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,544.95
|
| Rate for Payer: Ohio Health Group HMO |
$14,100.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,040.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,356.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,972.75
|
| Rate for Payer: PHCS Commercial |
$18,049.04
|
| Rate for Payer: United Healthcare All Payer |
$16,544.95
|
|
|
LESION EXC OF TENDON SHEATH
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
76100678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.98 |
| Max. Negotiated Rate |
$687.13 |
| Rate for Payer: Aetna Commercial |
$449.24
|
| Rate for Payer: Ambetter Exchange |
$302.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.82
|
| Rate for Payer: Anthem Medicaid |
$159.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$302.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$302.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$363.41
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$493.30
|
| Rate for Payer: Healthspan PPO |
$687.13
|
| Rate for Payer: Humana Medicaid |
$159.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$399.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$302.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$302.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.18
|
| Rate for Payer: Molina Healthcare Passport |
$159.98
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$393.69
|
| Rate for Payer: UHCCP Medicaid |
$170.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$302.84
|
|
|
LESION EXC OF TENDON SHEATH
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
76100678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
LESION EXC OF TENDON SHEATH
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
76100678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$343.90 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
LESION EXC OF TENDON SHEATH(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
761P0678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.98 |
| Max. Negotiated Rate |
$687.13 |
| Rate for Payer: Aetna Commercial |
$449.24
|
| Rate for Payer: Ambetter Exchange |
$302.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.82
|
| Rate for Payer: Anthem Medicaid |
$159.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$302.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$302.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$363.41
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$493.30
|
| Rate for Payer: Healthspan PPO |
$687.13
|
| Rate for Payer: Humana Medicaid |
$159.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$399.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$302.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$302.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.18
|
| Rate for Payer: Molina Healthcare Passport |
$159.98
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$393.69
|
| Rate for Payer: UHCCP Medicaid |
$170.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$302.84
|
|
|
LET ME CLARIFY
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
22200127
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
LET ME CLARIFY
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
22200127
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
LET ME CLARIFY
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200127
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
LETS TOPICAL GEL 3ML SYRINGE
|
Facility
|
IP
|
$10.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003160
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$10.47 |
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.51
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cigna Commercial |
$9.06
|
| Rate for Payer: First Health Commercial |
$10.36
|
| Rate for Payer: Humana Commercial |
$9.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.60
|
| Rate for Payer: Ohio Health Group HMO |
$8.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.53
|
| Rate for Payer: PHCS Commercial |
$10.47
|
| Rate for Payer: United Healthcare All Payer |
$9.60
|
|
|
LETS TOPICAL GEL 3ML SYRINGE
|
Facility
|
OP
|
$10.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003160
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$10.47 |
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Anthem Medicaid |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.51
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cigna Commercial |
$9.06
|
| Rate for Payer: First Health Commercial |
$10.36
|
| Rate for Payer: Humana Commercial |
$9.27
|
| Rate for Payer: Humana KY Medicaid |
$3.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.60
|
| Rate for Payer: Ohio Health Group HMO |
$8.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.53
|
| Rate for Payer: PHCS Commercial |
$10.47
|
| Rate for Payer: United Healthcare All Payer |
$9.60
|
|
|
LEUCOVORIN 50mg (500mg SDV)
|
Facility
|
IP
|
$479.60
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25004393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.88 |
| Max. Negotiated Rate |
$460.42 |
| Rate for Payer: Aetna Commercial |
$369.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$374.09
|
| Rate for Payer: Cash Price |
$239.80
|
| Rate for Payer: Cigna Commercial |
$398.07
|
| Rate for Payer: First Health Commercial |
$455.62
|
| Rate for Payer: Humana Commercial |
$407.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$393.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$353.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$422.05
|
| Rate for Payer: Ohio Health Group HMO |
$359.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$383.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$417.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.92
|
| Rate for Payer: PHCS Commercial |
$460.42
|
| Rate for Payer: United Healthcare All Payer |
$422.05
|
|
|
LEUCOVORIN 50mg (500mg SDV)
|
Facility
|
OP
|
$479.60
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25004393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.88 |
| Max. Negotiated Rate |
$460.42 |
| Rate for Payer: Aetna Commercial |
$369.29
|
| Rate for Payer: Anthem Medicaid |
$164.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$374.09
|
| Rate for Payer: Cash Price |
$239.80
|
| Rate for Payer: Cigna Commercial |
$398.07
|
| Rate for Payer: First Health Commercial |
$455.62
|
| Rate for Payer: Humana Commercial |
$407.66
|
| Rate for Payer: Humana KY Medicaid |
$164.93
|
| Rate for Payer: Kentucky WC Medicaid |
$166.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$393.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$353.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$168.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$422.05
|
| Rate for Payer: Ohio Health Group HMO |
$359.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$383.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$417.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.92
|
| Rate for Payer: PHCS Commercial |
$460.42
|
| Rate for Payer: United Healthcare All Payer |
$422.05
|
|
|
LEUCOVORIN 50MG/5ML(100MG/10ML
|
Facility
|
IP
|
$87.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.16 |
| Max. Negotiated Rate |
$83.71 |
| Rate for Payer: Aetna Commercial |
$67.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.02
|
| Rate for Payer: Cash Price |
$43.60
|
| Rate for Payer: Cigna Commercial |
$72.38
|
| Rate for Payer: First Health Commercial |
$82.84
|
| Rate for Payer: Humana Commercial |
$74.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.74
|
| Rate for Payer: Ohio Health Group HMO |
$65.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.17
|
| Rate for Payer: PHCS Commercial |
$83.71
|
| Rate for Payer: United Healthcare All Payer |
$76.74
|
|
|
LEUCOVORIN 50MG/5ML(100MG/10ML
|
Facility
|
OP
|
$87.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.16 |
| Max. Negotiated Rate |
$83.71 |
| Rate for Payer: Aetna Commercial |
$67.14
|
| Rate for Payer: Anthem Medicaid |
$29.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.02
|
| Rate for Payer: Cash Price |
$43.60
|
| Rate for Payer: Cigna Commercial |
$72.38
|
| Rate for Payer: First Health Commercial |
$82.84
|
| Rate for Payer: Humana Commercial |
$74.12
|
| Rate for Payer: Humana KY Medicaid |
$29.99
|
| Rate for Payer: Kentucky WC Medicaid |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.74
|
| Rate for Payer: Ohio Health Group HMO |
$65.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.17
|
| Rate for Payer: PHCS Commercial |
$83.71
|
| Rate for Payer: United Healthcare All Payer |
$76.74
|
|
|
LEUCOVORIN CA 50MG 200MG V
|
Facility
|
IP
|
$130.80
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$125.57 |
| Rate for Payer: Aetna Commercial |
$100.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.02
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: First Health Commercial |
$124.26
|
| Rate for Payer: Humana Commercial |
$111.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.10
|
| Rate for Payer: Ohio Health Group HMO |
$98.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$113.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.25
|
| Rate for Payer: PHCS Commercial |
$125.57
|
| Rate for Payer: United Healthcare All Payer |
$115.10
|
|
|
LEUCOVORIN CA 50MG 200MG V
|
Facility
|
OP
|
$130.80
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$125.57 |
| Rate for Payer: Aetna Commercial |
$100.72
|
| Rate for Payer: Anthem Medicaid |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.02
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: First Health Commercial |
$124.26
|
| Rate for Payer: Humana Commercial |
$111.18
|
| Rate for Payer: Humana KY Medicaid |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$45.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.10
|
| Rate for Payer: Ohio Health Group HMO |
$98.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$113.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.25
|
| Rate for Payer: PHCS Commercial |
$125.57
|
| Rate for Payer: United Healthcare All Payer |
$115.10
|
|
|
LEUCOVORIN CALC 50MG350MG VL
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.70 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem Medicaid |
$116.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Humana KY Medicaid |
$116.58
|
| Rate for Payer: Kentucky WC Medicaid |
$117.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$118.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$271.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$233.91
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
LEUCOVORIN CALC 50MG350MG VL
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.70 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$271.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$233.91
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
LEUCOVORIN CALCIUM 50MG VIAL
|
Facility
|
IP
|
$115.80
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$111.17 |
| Rate for Payer: Aetna Commercial |
$89.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$96.11
|
| Rate for Payer: First Health Commercial |
$110.01
|
| Rate for Payer: Humana Commercial |
$98.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.90
|
| Rate for Payer: Ohio Health Group HMO |
$86.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.90
|
| Rate for Payer: PHCS Commercial |
$111.17
|
| Rate for Payer: United Healthcare All Payer |
$101.90
|
|
|
LEUCOVORIN CALCIUM 50MG VIAL
|
Facility
|
OP
|
$115.80
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$111.17 |
| Rate for Payer: Aetna Commercial |
$89.17
|
| Rate for Payer: Anthem Medicaid |
$39.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$96.11
|
| Rate for Payer: First Health Commercial |
$110.01
|
| Rate for Payer: Humana Commercial |
$98.43
|
| Rate for Payer: Humana KY Medicaid |
$39.82
|
| Rate for Payer: Kentucky WC Medicaid |
$40.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.90
|
| Rate for Payer: Ohio Health Group HMO |
$86.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.90
|
| Rate for Payer: PHCS Commercial |
$111.17
|
| Rate for Payer: United Healthcare All Payer |
$101.90
|
|
|
LEUCOVORIN CALCIUM 5MG TABLET
|
Facility
|
IP
|
$9.12
|
|
|
Service Code
|
NDC 54449613
|
| Hospital Charge Code |
25000854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| 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 |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
LEUCOVORIN CALCIUM 5MG TABLET
|
Facility
|
OP
|
$9.12
|
|
|
Service Code
|
NDC 54449613
|
| Hospital Charge Code |
25000854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| 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 |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
