|
LEUKOREDUCED PRC IRRADIATED
|
Facility
|
OP
|
$612.00
|
|
|
Service Code
|
HCPCS P9040
|
| Hospital Charge Code |
38000015
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$210.47 |
| Max. Negotiated Rate |
$587.52 |
| Rate for Payer: Aetna Commercial |
$471.24
|
| Rate for Payer: Anthem Medicaid |
$210.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$236.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$477.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$330.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.07
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$507.96
|
| Rate for Payer: First Health Commercial |
$581.40
|
| Rate for Payer: Humana Commercial |
$520.20
|
| Rate for Payer: Humana KY Medicaid |
$210.47
|
| Rate for Payer: Humana Medicare Advantage |
$236.35
|
| Rate for Payer: Kentucky WC Medicaid |
$212.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$501.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$451.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$283.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$214.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$538.56
|
| Rate for Payer: Ohio Health Group HMO |
$459.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$489.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$422.28
|
| Rate for Payer: PHCS Commercial |
$587.52
|
| Rate for Payer: United Healthcare All Payer |
$538.56
|
|
|
LEUKOREDUCED PRC IRRADIATED
|
Facility
|
IP
|
$612.00
|
|
|
Service Code
|
HCPCS P9040
|
| Hospital Charge Code |
38000015
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$183.60 |
| Max. Negotiated Rate |
$587.52 |
| Rate for Payer: Aetna Commercial |
$471.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$477.36
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$507.96
|
| Rate for Payer: First Health Commercial |
$581.40
|
| Rate for Payer: Humana Commercial |
$520.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$501.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$451.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$538.56
|
| Rate for Payer: Ohio Health Group HMO |
$459.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$489.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$422.28
|
| Rate for Payer: PHCS Commercial |
$587.52
|
| Rate for Payer: United Healthcare All Payer |
$538.56
|
|
|
LEVABID (HYOSCYAMINE)0.37 MG T
|
Facility
|
IP
|
$22.05
|
|
|
Service Code
|
NDC 68220011510
|
| Hospital Charge Code |
25000855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.62 |
| Max. Negotiated Rate |
$21.17 |
| Rate for Payer: Aetna Commercial |
$16.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.20
|
| Rate for Payer: Cash Price |
$11.03
|
| Rate for Payer: Cigna Commercial |
$18.30
|
| Rate for Payer: First Health Commercial |
$20.95
|
| Rate for Payer: Humana Commercial |
$18.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.40
|
| Rate for Payer: Ohio Health Group HMO |
$16.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.21
|
| Rate for Payer: PHCS Commercial |
$21.17
|
| Rate for Payer: United Healthcare All Payer |
$19.40
|
|
|
LEVABID (HYOSCYAMINE)0.37 MG T
|
Facility
|
OP
|
$22.05
|
|
|
Service Code
|
NDC 68220011510
|
| Hospital Charge Code |
25000855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.62 |
| Max. Negotiated Rate |
$21.17 |
| Rate for Payer: Aetna Commercial |
$16.98
|
| Rate for Payer: Anthem Medicaid |
$7.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.20
|
| Rate for Payer: Cash Price |
$11.03
|
| Rate for Payer: Cigna Commercial |
$18.30
|
| Rate for Payer: First Health Commercial |
$20.95
|
| Rate for Payer: Humana Commercial |
$18.74
|
| Rate for Payer: Humana KY Medicaid |
$7.58
|
| Rate for Payer: Kentucky WC Medicaid |
$7.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.40
|
| Rate for Payer: Ohio Health Group HMO |
$16.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.21
|
| Rate for Payer: PHCS Commercial |
$21.17
|
| Rate for Payer: United Healthcare All Payer |
$19.40
|
|
|
LEVAQUIN (LEVOFLOX)250MG50ML
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.90 |
| 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 |
$90.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.97
|
| 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 |
$33.90 |
| 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 |
$90.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.97
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
LEVAQUIN (LEVOFLOX 500G/100ML)
|
Facility
|
IP
|
$113.12
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.94 |
| 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 |
$90.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.05
|
| Rate for Payer: PHCS Commercial |
$108.60
|
| Rate for Payer: United Healthcare All Payer |
$99.55
|
|
|
LEVAQUIN (LEVOFLOX 500G/100ML)
|
Facility
|
OP
|
$113.12
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.94 |
| 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 |
$90.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.05
|
| Rate for Payer: PHCS Commercial |
$108.60
|
| Rate for Payer: United Healthcare All Payer |
$99.55
|
|
|
LEVAQUIN (LEVOFLOXACIN) 250 MG
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 65862053650
|
| Hospital Charge Code |
25000856
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
LEVAQUIN (LEVOFLOXACIN) 250 MG
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 65862053650
|
| Hospital Charge Code |
25000856
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| 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 |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| 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 |
$1.39 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| 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 |
$1.39 |
| Max. Negotiated Rate |
$4.45 |
| 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
|
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
LEVAQUIN (LVFLXC)750MG/150ML
|
Facility
|
OP
|
$113.50
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
25002211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.05 |
| Max. Negotiated Rate |
$108.96 |
| Rate for Payer: Aetna Commercial |
$87.39
|
| 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 |
$107.83
|
| Rate for Payer: Humana Commercial |
$96.47
|
| 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 |
$90.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.31
|
| 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 |
$34.05 |
| Max. Negotiated Rate |
$108.96 |
| Rate for Payer: Aetna Commercial |
$87.39
|
| 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 |
$107.83
|
| Rate for Payer: Humana Commercial |
$96.47
|
| 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 |
$90.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.31
|
| Rate for Payer: PHCS Commercial |
$108.96
|
| Rate for Payer: United Healthcare All Payer |
$99.88
|
|
|
LEVAQUIT(LEVAFLOXAC 500MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 904635261
|
| Hospital Charge Code |
25000858
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
LEVAQUIT(LEVAFLOXAC 500MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 904635261
|
| Hospital Charge Code |
25000858
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY
|
Professional
|
Both
|
$940.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
40200053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$44.97 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Ambetter Exchange |
$175.71
|
| Rate for Payer: Anthem Medicaid |
$71.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$175.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$210.85
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$175.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.80
|
| Rate for Payer: Molina Healthcare Passport |
$71.37
|
| Rate for Payer: Multiplan PHCS |
$564.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$228.42
|
| Rate for Payer: UHCCP Medicaid |
$329.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$175.71
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY
|
Facility
|
IP
|
$940.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
40200053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$282.00 |
| Max. Negotiated Rate |
$902.40 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$282.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$817.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$648.60
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
40200053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$902.40 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem Medicaid |
$323.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Humana KY Medicaid |
$323.27
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$326.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$329.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$817.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$648.60
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
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 |
$228.42 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Ambetter Exchange |
$175.71
|
| Rate for Payer: Anthem Medicaid |
$71.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$175.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$210.85
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$175.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.71
|
| 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 |
$228.42
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$175.71
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY(T
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
402T0053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$237.00 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.10
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
LEVEL 2 IMAG W/O CON UROLOGY(T
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
HCPCS 76872
|
| Hospital Charge Code |
402T0053
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem Medicaid |
$271.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Humana KY Medicaid |
$271.68
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$274.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$277.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.10
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
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 |
$138.00 |
| Rate for Payer: Aetna Commercial |
$72.79
|
| Rate for Payer: Ambetter Exchange |
$29.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$29.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$29.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.90
|
| 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: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$29.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.92
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.90
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$29.92
|
|
|
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 |
$69.00 |
| 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 |
$184.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.70
|
| 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 |
$36.27 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem Medicaid |
$36.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$184.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.27
|
| 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 |
$36.27
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$36.63
|
| 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 |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.00
|
| 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 |
$184.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$200.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.70
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
