|
LEVEL3 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS 88304
|
| Hospital Charge Code |
30001504
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna Commercial |
$194.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.36
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$209.16
|
| Rate for Payer: First Health Commercial |
$239.40
|
| Rate for Payer: Humana Commercial |
$214.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.76
|
| Rate for Payer: Ohio Health Group HMO |
$189.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.88
|
| Rate for Payer: PHCS Commercial |
$241.92
|
| Rate for Payer: United Healthcare All Payer |
$221.76
|
|
|
LEVEL3 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS 88304
|
| Hospital Charge Code |
30001504
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna Commercial |
$194.04
|
| Rate for Payer: Anthem Medicaid |
$49.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.37
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$209.16
|
| Rate for Payer: First Health Commercial |
$239.40
|
| Rate for Payer: Humana Commercial |
$214.20
|
| Rate for Payer: Humana KY Medicaid |
$49.37
|
| Rate for Payer: Humana Medicare Advantage |
$49.37
|
| Rate for Payer: Kentucky WC Medicaid |
$49.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.76
|
| Rate for Payer: Ohio Health Group HMO |
$189.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.88
|
| Rate for Payer: PHCS Commercial |
$241.92
|
| Rate for Payer: United Healthcare All Payer |
$221.76
|
|
|
LEVEL3 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS 88304
|
| Hospital Charge Code |
30001504
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$151.20 |
| Rate for Payer: Aetna Commercial |
$92.45
|
| Rate for Payer: Ambetter Exchange |
$38.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.12
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$38.71
|
| Rate for Payer: Healthspan PPO |
$87.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.43
|
| Rate for Payer: Multiplan PHCS |
$151.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.96
|
| Rate for Payer: UHCCP Medicaid |
$88.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.43
|
|
|
LEVEL4 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$267.00
|
|
|
Service Code
|
HCPCS 88305
|
| Hospital Charge Code |
30001507
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$160.20 |
| Rate for Payer: Aetna Commercial |
$158.53
|
| Rate for Payer: Ambetter Exchange |
$65.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$65.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$65.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$78.71
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$66.15
|
| Rate for Payer: Healthspan PPO |
$150.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.40
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$65.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.59
|
| Rate for Payer: Multiplan PHCS |
$160.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$85.27
|
| Rate for Payer: UHCCP Medicaid |
$93.45
|
| Rate for Payer: United Healthcare Non-Options |
$35.65
|
| Rate for Payer: United Healthcare Options |
$35.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$65.59
|
|
|
LEVEL4 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
HCPCS 88305
|
| Hospital Charge Code |
30001507
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: Aetna Commercial |
$205.59
|
| Rate for Payer: Anthem Medicaid |
$49.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.37
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$221.61
|
| Rate for Payer: First Health Commercial |
$253.65
|
| Rate for Payer: Humana Commercial |
$226.95
|
| Rate for Payer: Humana KY Medicaid |
$49.37
|
| Rate for Payer: Humana Medicare Advantage |
$49.37
|
| Rate for Payer: Kentucky WC Medicaid |
$49.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$234.96
|
| Rate for Payer: Ohio Health Group HMO |
$200.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.23
|
| Rate for Payer: PHCS Commercial |
$256.32
|
| Rate for Payer: United Healthcare All Payer |
$234.96
|
|
|
LEVEL4 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
HCPCS 88305
|
| Hospital Charge Code |
30001507
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: Aetna Commercial |
$205.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$214.40
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$221.61
|
| Rate for Payer: First Health Commercial |
$253.65
|
| Rate for Payer: Humana Commercial |
$226.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$234.96
|
| Rate for Payer: Ohio Health Group HMO |
$200.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.23
|
| Rate for Payer: PHCS Commercial |
$256.32
|
| Rate for Payer: United Healthcare All Payer |
$234.96
|
|
|
LEVEL5 SURG PATH GROSS/MIC EX
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
HCPCS 88309
|
| Hospital Charge Code |
30001509
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$74.35 |
| Max. Negotiated Rate |
$502.76 |
| Rate for Payer: Aetna Commercial |
$477.76
|
| Rate for Payer: Ambetter Exchange |
$386.74
|
| Rate for Payer: Buckeye Individual/Medicaid |
$386.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$386.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$464.09
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$184.67
|
| Rate for Payer: Healthspan PPO |
$453.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$74.35
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$386.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$386.74
|
| Rate for Payer: Multiplan PHCS |
$336.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$502.76
|
| Rate for Payer: UHCCP Medicaid |
$196.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$139.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$386.74
|
|
|
LEVEL5 SURG PATH GROSS/MIC EX
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS 88309
|
| Hospital Charge Code |
30001509
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$168.30 |
| Max. Negotiated Rate |
$538.56 |
| Rate for Payer: Aetna Commercial |
$431.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.48
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$465.63
|
| Rate for Payer: First Health Commercial |
$532.95
|
| Rate for Payer: Humana Commercial |
$476.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$460.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$414.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$493.68
|
| Rate for Payer: Ohio Health Group HMO |
$420.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$488.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.09
|
| Rate for Payer: PHCS Commercial |
$538.56
|
| Rate for Payer: United Healthcare All Payer |
$493.68
|
|
|
LEVEL5 SURG PATH GROSS/MIC EX
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS 88309
|
| Hospital Charge Code |
30001509
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$387.09 |
| Max. Negotiated Rate |
$1,056.72 |
| Rate for Payer: Aetna Commercial |
$431.97
|
| Rate for Payer: Anthem Medicaid |
$754.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$754.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,056.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$754.80
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$465.63
|
| Rate for Payer: First Health Commercial |
$532.95
|
| Rate for Payer: Humana Commercial |
$476.85
|
| Rate for Payer: Humana KY Medicaid |
$754.80
|
| Rate for Payer: Humana Medicare Advantage |
$754.80
|
| Rate for Payer: Kentucky WC Medicaid |
$762.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$460.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$414.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$905.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$769.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$493.68
|
| Rate for Payer: Ohio Health Group HMO |
$420.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$488.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.09
|
| Rate for Payer: PHCS Commercial |
$538.56
|
| Rate for Payer: United Healthcare All Payer |
$493.68
|
|
|
LEVEL 6 SPEC DEV PROC EA 15MIN
|
Facility
|
IP
|
$5,316.00
|
|
| Hospital Charge Code |
36001262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,594.80 |
| Max. Negotiated Rate |
$5,103.36 |
| Rate for Payer: Aetna Commercial |
$4,093.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,146.48
|
| Rate for Payer: Cash Price |
$2,658.00
|
| Rate for Payer: Cigna Commercial |
$4,412.28
|
| Rate for Payer: First Health Commercial |
$5,050.20
|
| Rate for Payer: Humana Commercial |
$4,518.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,359.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,923.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,594.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,678.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,987.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,252.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,624.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,668.04
|
| Rate for Payer: PHCS Commercial |
$5,103.36
|
| Rate for Payer: United Healthcare All Payer |
$4,678.08
|
|
|
LEVEL 6 SPEC DEV PROC EA 15MIN
|
Facility
|
OP
|
$5,316.00
|
|
| Hospital Charge Code |
36001262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,594.80 |
| Max. Negotiated Rate |
$5,103.36 |
| Rate for Payer: Aetna Commercial |
$4,093.32
|
| Rate for Payer: Anthem Medicaid |
$1,828.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,146.48
|
| Rate for Payer: Cash Price |
$2,658.00
|
| Rate for Payer: Cigna Commercial |
$4,412.28
|
| Rate for Payer: First Health Commercial |
$5,050.20
|
| Rate for Payer: Humana Commercial |
$4,518.60
|
| Rate for Payer: Humana KY Medicaid |
$1,828.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,846.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,359.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,923.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,594.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,864.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,678.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,987.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,252.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,624.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,668.04
|
| Rate for Payer: PHCS Commercial |
$5,103.36
|
| Rate for Payer: United Healthcare All Payer |
$4,678.08
|
|
|
LEVEL 6 SPEDEV PROC 15MIN CATH
|
Facility
|
IP
|
$5,276.00
|
|
| Hospital Charge Code |
48100098
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,582.80 |
| Max. Negotiated Rate |
$5,064.96 |
| Rate for Payer: Aetna Commercial |
$4,062.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,115.28
|
| Rate for Payer: Cash Price |
$2,638.00
|
| Rate for Payer: Cigna Commercial |
$4,379.08
|
| Rate for Payer: First Health Commercial |
$5,012.20
|
| Rate for Payer: Humana Commercial |
$4,484.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,326.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,893.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,642.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,957.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,590.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,640.44
|
| Rate for Payer: PHCS Commercial |
$5,064.96
|
| Rate for Payer: United Healthcare All Payer |
$4,642.88
|
|
|
LEVEL 6 SPEDEV PROC 15MIN CATH
|
Facility
|
OP
|
$5,276.00
|
|
| Hospital Charge Code |
48100098
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,582.80 |
| Max. Negotiated Rate |
$5,064.96 |
| Rate for Payer: Aetna Commercial |
$4,062.52
|
| Rate for Payer: Anthem Medicaid |
$1,814.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,115.28
|
| Rate for Payer: Cash Price |
$2,638.00
|
| Rate for Payer: Cigna Commercial |
$4,379.08
|
| Rate for Payer: First Health Commercial |
$5,012.20
|
| Rate for Payer: Humana Commercial |
$4,484.60
|
| Rate for Payer: Humana KY Medicaid |
$1,814.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,832.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,326.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,893.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,850.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,642.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,957.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,590.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,640.44
|
| Rate for Payer: PHCS Commercial |
$5,064.96
|
| Rate for Payer: United Healthcare All Payer |
$4,642.88
|
|
|
LEVEMIR FLX PEN 100 U/ML 3mL
|
Facility
|
OP
|
$63.29
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$60.76 |
| Rate for Payer: Aetna Commercial |
$48.73
|
| Rate for Payer: Anthem Medicaid |
$21.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.37
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cigna Commercial |
$52.53
|
| Rate for Payer: First Health Commercial |
$60.13
|
| Rate for Payer: Humana Commercial |
$53.80
|
| Rate for Payer: Humana KY Medicaid |
$21.77
|
| Rate for Payer: Kentucky WC Medicaid |
$21.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.70
|
| Rate for Payer: Ohio Health Group HMO |
$47.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.67
|
| Rate for Payer: PHCS Commercial |
$60.76
|
| Rate for Payer: United Healthcare All Payer |
$55.70
|
|
|
LEVEMIR FLX PEN 100 U/ML 3mL
|
Facility
|
IP
|
$63.29
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$60.76 |
| Rate for Payer: Aetna Commercial |
$48.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.37
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cigna Commercial |
$52.53
|
| Rate for Payer: First Health Commercial |
$60.13
|
| Rate for Payer: Humana Commercial |
$53.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.70
|
| Rate for Payer: Ohio Health Group HMO |
$47.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.67
|
| Rate for Payer: PHCS Commercial |
$60.76
|
| Rate for Payer: United Healthcare All Payer |
$55.70
|
|
|
LEVETIRACETAM 10mg(250mg/50mL)
|
Facility
|
IP
|
$42.29
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.69 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna Commercial |
$32.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.99
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: Cigna Commercial |
$35.10
|
| Rate for Payer: First Health Commercial |
$40.18
|
| Rate for Payer: Humana Commercial |
$35.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.22
|
| Rate for Payer: Ohio Health Group HMO |
$31.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.18
|
| Rate for Payer: PHCS Commercial |
$40.60
|
| Rate for Payer: United Healthcare All Payer |
$37.22
|
|
|
LEVETIRACETAM 10mg(250mg/50mL)
|
Facility
|
OP
|
$42.29
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.69 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna Commercial |
$32.56
|
| Rate for Payer: Anthem Medicaid |
$14.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.99
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: Cigna Commercial |
$35.10
|
| Rate for Payer: First Health Commercial |
$40.18
|
| Rate for Payer: Humana Commercial |
$35.95
|
| Rate for Payer: Humana KY Medicaid |
$14.54
|
| Rate for Payer: Kentucky WC Medicaid |
$14.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.22
|
| Rate for Payer: Ohio Health Group HMO |
$31.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.18
|
| Rate for Payer: PHCS Commercial |
$40.60
|
| Rate for Payer: United Healthcare All Payer |
$37.22
|
|
|
LEVETIRACETAM 10mg(500mg100mL)
|
Facility
|
OP
|
$100.83
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$96.80 |
| Rate for Payer: Aetna Commercial |
$77.64
|
| Rate for Payer: Anthem Medicaid |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.65
|
| Rate for Payer: Cash Price |
$50.42
|
| Rate for Payer: Cigna Commercial |
$83.69
|
| Rate for Payer: First Health Commercial |
$95.79
|
| Rate for Payer: Humana Commercial |
$85.71
|
| Rate for Payer: Humana KY Medicaid |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$35.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.73
|
| Rate for Payer: Ohio Health Group HMO |
$75.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.57
|
| Rate for Payer: PHCS Commercial |
$96.80
|
| Rate for Payer: United Healthcare All Payer |
$88.73
|
|
|
LEVETIRACETAM 10mg(500mg100mL)
|
Facility
|
IP
|
$100.83
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$96.80 |
| Rate for Payer: Aetna Commercial |
$77.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.65
|
| Rate for Payer: Cash Price |
$50.42
|
| Rate for Payer: Cigna Commercial |
$83.69
|
| Rate for Payer: First Health Commercial |
$95.79
|
| Rate for Payer: Humana Commercial |
$85.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.73
|
| Rate for Payer: Ohio Health Group HMO |
$75.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.57
|
| Rate for Payer: PHCS Commercial |
$96.80
|
| Rate for Payer: United Healthcare All Payer |
$88.73
|
|
|
LEVISIN(HYSCYAM)0.125MG/5MLELX
|
Facility
|
IP
|
$9.11
|
|
|
Service Code
|
NDC 39328004816
|
| Hospital Charge Code |
25000861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| 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 |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
LEVISIN(HYSCYAM)0.125MG/5MLELX
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 39328004816
|
| Hospital Charge Code |
25000861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| 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 |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
LEVOCARNITINE 1 GM/5 ML VIAL
|
Facility
|
OP
|
$194.87
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
25003162
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.46 |
| Max. Negotiated Rate |
$187.08 |
| Rate for Payer: Aetna Commercial |
$150.05
|
| Rate for Payer: Anthem Medicaid |
$67.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.00
|
| Rate for Payer: Cash Price |
$97.44
|
| Rate for Payer: Cigna Commercial |
$161.74
|
| Rate for Payer: First Health Commercial |
$185.13
|
| Rate for Payer: Humana Commercial |
$165.64
|
| Rate for Payer: Humana KY Medicaid |
$67.02
|
| Rate for Payer: Kentucky WC Medicaid |
$67.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$171.49
|
| Rate for Payer: Ohio Health Group HMO |
$146.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$134.46
|
| Rate for Payer: PHCS Commercial |
$187.08
|
| Rate for Payer: United Healthcare All Payer |
$171.49
|
|
|
LEVOCARNITINE 1 GM/5 ML VIAL
|
Facility
|
IP
|
$194.87
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
25003162
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.46 |
| Max. Negotiated Rate |
$187.08 |
| Rate for Payer: Aetna Commercial |
$150.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.00
|
| Rate for Payer: Cash Price |
$97.44
|
| Rate for Payer: Cigna Commercial |
$161.74
|
| Rate for Payer: First Health Commercial |
$185.13
|
| Rate for Payer: Humana Commercial |
$165.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$171.49
|
| Rate for Payer: Ohio Health Group HMO |
$146.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$134.46
|
| Rate for Payer: PHCS Commercial |
$187.08
|
| Rate for Payer: United Healthcare All Payer |
$171.49
|
|
|
LEVOPHED (NOREPINEPHRI 4MG/4ML
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
NDC 781375575
|
| Hospital Charge Code |
25003163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$112.80 |
| Rate for Payer: Aetna Commercial |
$90.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.65
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cigna Commercial |
$97.53
|
| Rate for Payer: First Health Commercial |
$111.62
|
| Rate for Payer: Humana Commercial |
$99.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.40
|
| Rate for Payer: Ohio Health Group HMO |
$88.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.08
|
| Rate for Payer: PHCS Commercial |
$112.80
|
| Rate for Payer: United Healthcare All Payer |
$103.40
|
|
|
LEVOPHED (NOREPINEPHRI 4MG/4ML
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
NDC 781375575
|
| Hospital Charge Code |
25003163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$112.80 |
| Rate for Payer: Aetna Commercial |
$90.47
|
| Rate for Payer: Anthem Medicaid |
$40.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.65
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cigna Commercial |
$97.53
|
| Rate for Payer: First Health Commercial |
$111.62
|
| Rate for Payer: Humana Commercial |
$99.88
|
| Rate for Payer: Humana KY Medicaid |
$40.41
|
| Rate for Payer: Kentucky WC Medicaid |
$40.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.40
|
| Rate for Payer: Ohio Health Group HMO |
$88.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.08
|
| Rate for Payer: PHCS Commercial |
$112.80
|
| Rate for Payer: United Healthcare All Payer |
$103.40
|
|
