|
L HRT ART/GRFT ANGIO
|
Facility
|
IP
|
$19,291.00
|
|
|
Service Code
|
HCPCS 93459
|
| Hospital Charge Code |
48100070
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$5,787.30 |
| Max. Negotiated Rate |
$18,519.36 |
| Rate for Payer: Aetna Commercial |
$14,854.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,046.98
|
| Rate for Payer: Cash Price |
$9,645.50
|
| Rate for Payer: Cigna Commercial |
$16,011.53
|
| Rate for Payer: First Health Commercial |
$18,326.45
|
| Rate for Payer: Humana Commercial |
$16,397.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,818.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,236.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,787.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,976.08
|
| Rate for Payer: Ohio Health Group HMO |
$14,468.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,432.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,783.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,310.79
|
| Rate for Payer: PHCS Commercial |
$18,519.36
|
| Rate for Payer: United Healthcare All Payer |
$16,976.08
|
|
|
L HRT ART/GRFT ANGIO(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 93459
|
| Hospital Charge Code |
761P2483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$2,002.24 |
| Rate for Payer: Aetna Commercial |
$1,827.80
|
| Rate for Payer: Ambetter Exchange |
$967.57
|
| Rate for Payer: Anthem Medicaid |
$1,017.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$967.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$967.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,161.08
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$2,002.24
|
| Rate for Payer: Healthspan PPO |
$1,358.82
|
| Rate for Payer: Humana Medicaid |
$1,017.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$490.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$967.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$967.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,037.73
|
| Rate for Payer: Molina Healthcare Passport |
$1,017.38
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,257.84
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,027.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$967.57
|
|
|
L HRT ART/GRFT ANGIO(T
|
Facility
|
IP
|
$18,638.00
|
|
|
Service Code
|
HCPCS 93459
|
| Hospital Charge Code |
761T2483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$5,591.40 |
| Max. Negotiated Rate |
$17,892.48 |
| Rate for Payer: Aetna Commercial |
$14,351.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,537.64
|
| Rate for Payer: Cash Price |
$9,319.00
|
| Rate for Payer: Cigna Commercial |
$15,469.54
|
| Rate for Payer: First Health Commercial |
$17,706.10
|
| Rate for Payer: Humana Commercial |
$15,842.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,283.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,754.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,591.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,401.44
|
| Rate for Payer: Ohio Health Group HMO |
$13,978.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,910.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,215.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,860.22
|
| Rate for Payer: PHCS Commercial |
$17,892.48
|
| Rate for Payer: United Healthcare All Payer |
$16,401.44
|
|
|
L HRT ART/GRFT ANGIO(T
|
Facility
|
OP
|
$18,638.00
|
|
|
Service Code
|
HCPCS 93459
|
| Hospital Charge Code |
761T2483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,971.90 |
| Max. Negotiated Rate |
$17,892.48 |
| Rate for Payer: Aetna Commercial |
$14,351.26
|
| Rate for Payer: Anthem Medicaid |
$6,409.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,971.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,537.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,160.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,012.07
|
| Rate for Payer: Cash Price |
$9,319.00
|
| Rate for Payer: Cash Price |
$9,319.00
|
| Rate for Payer: Cigna Commercial |
$15,469.54
|
| Rate for Payer: First Health Commercial |
$17,706.10
|
| Rate for Payer: Humana Commercial |
$15,842.30
|
| Rate for Payer: Humana KY Medicaid |
$6,409.61
|
| Rate for Payer: Humana Medicare Advantage |
$2,971.90
|
| Rate for Payer: Kentucky WC Medicaid |
$6,474.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,283.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,754.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,566.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,538.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,401.44
|
| Rate for Payer: Ohio Health Group HMO |
$13,978.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,910.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,215.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,860.22
|
| Rate for Payer: PHCS Commercial |
$17,892.48
|
| Rate for Payer: United Healthcare All Payer |
$16,401.44
|
|
|
L HRT CATH TRNSPTL PUNCTURE
|
Facility
|
IP
|
$427.00
|
|
|
Service Code
|
HCPCS 93462
|
| Hospital Charge Code |
48000095
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$128.10 |
| Max. Negotiated Rate |
$409.92 |
| Rate for Payer: Aetna Commercial |
$328.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$333.06
|
| Rate for Payer: Cash Price |
$213.50
|
| Rate for Payer: Cigna Commercial |
$354.41
|
| Rate for Payer: First Health Commercial |
$405.65
|
| Rate for Payer: Humana Commercial |
$362.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$350.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$315.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$128.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$375.76
|
| Rate for Payer: Ohio Health Group HMO |
$320.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$341.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$371.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$294.63
|
| Rate for Payer: PHCS Commercial |
$409.92
|
| Rate for Payer: United Healthcare All Payer |
$375.76
|
|
|
L HRT CATH TRNSPTL PUNCTURE
|
Facility
|
OP
|
$427.00
|
|
|
Service Code
|
HCPCS 93462
|
| Hospital Charge Code |
48000095
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$128.10 |
| Max. Negotiated Rate |
$409.92 |
| Rate for Payer: Aetna Commercial |
$328.79
|
| Rate for Payer: Anthem Medicaid |
$146.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$333.06
|
| Rate for Payer: Cash Price |
$213.50
|
| Rate for Payer: Cigna Commercial |
$354.41
|
| Rate for Payer: First Health Commercial |
$405.65
|
| Rate for Payer: Humana Commercial |
$362.95
|
| Rate for Payer: Humana KY Medicaid |
$146.85
|
| Rate for Payer: Kentucky WC Medicaid |
$148.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$350.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$315.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$128.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$375.76
|
| Rate for Payer: Ohio Health Group HMO |
$320.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$341.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$371.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$294.63
|
| Rate for Payer: PHCS Commercial |
$409.92
|
| Rate for Payer: United Healthcare All Payer |
$375.76
|
|
|
LIBRAX(CHLORDIAZEP/CLIDIN 1CAP
|
Facility
|
OP
|
$87.45
|
|
|
Service Code
|
NDC 187410010
|
| Hospital Charge Code |
25000867
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$83.95 |
| Rate for Payer: Aetna Commercial |
$67.34
|
| Rate for Payer: Anthem Medicaid |
$30.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.21
|
| Rate for Payer: Cash Price |
$43.73
|
| Rate for Payer: Cigna Commercial |
$72.58
|
| Rate for Payer: First Health Commercial |
$83.08
|
| Rate for Payer: Humana Commercial |
$74.33
|
| Rate for Payer: Humana KY Medicaid |
$30.07
|
| Rate for Payer: Kentucky WC Medicaid |
$30.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.96
|
| Rate for Payer: Ohio Health Group HMO |
$65.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.34
|
| Rate for Payer: PHCS Commercial |
$83.95
|
| Rate for Payer: United Healthcare All Payer |
$76.96
|
|
|
LIBRAX(CHLORDIAZEP/CLIDIN 1CAP
|
Facility
|
IP
|
$87.45
|
|
|
Service Code
|
NDC 187410010
|
| Hospital Charge Code |
25000867
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$83.95 |
| Rate for Payer: Aetna Commercial |
$67.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.21
|
| Rate for Payer: Cash Price |
$43.73
|
| Rate for Payer: Cigna Commercial |
$72.58
|
| Rate for Payer: First Health Commercial |
$83.08
|
| Rate for Payer: Humana Commercial |
$74.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.96
|
| Rate for Payer: Ohio Health Group HMO |
$65.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.34
|
| Rate for Payer: PHCS Commercial |
$83.95
|
| Rate for Payer: United Healthcare All Payer |
$76.96
|
|
|
LIBTAYO 1mg (350mg Vial)
|
Facility
|
OP
|
$59,541.03
|
|
|
Service Code
|
HCPCS J9119
|
| Hospital Charge Code |
25004042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$57,159.39 |
| Rate for Payer: Aetna Commercial |
$45,846.59
|
| Rate for Payer: Anthem Medicaid |
$20,476.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46,442.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$40.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.74
|
| Rate for Payer: Cash Price |
$29,770.52
|
| Rate for Payer: Cash Price |
$29,770.52
|
| Rate for Payer: Cigna Commercial |
$49,419.05
|
| Rate for Payer: First Health Commercial |
$56,563.98
|
| Rate for Payer: Humana Commercial |
$50,609.88
|
| Rate for Payer: Humana KY Medicaid |
$20,476.16
|
| Rate for Payer: Humana Medicare Advantage |
$28.70
|
| Rate for Payer: Kentucky WC Medicaid |
$20,684.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$48,823.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$43,941.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,886.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$52,396.11
|
| Rate for Payer: Ohio Health Group HMO |
$44,655.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47,632.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51,800.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41,083.31
|
| Rate for Payer: PHCS Commercial |
$57,159.39
|
| Rate for Payer: United Healthcare All Payer |
$52,396.11
|
|
|
LIBTAYO 1mg (350mg Vial)
|
Facility
|
IP
|
$59,541.03
|
|
|
Service Code
|
HCPCS J9119
|
| Hospital Charge Code |
25004042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17,862.31 |
| Max. Negotiated Rate |
$57,159.39 |
| Rate for Payer: Aetna Commercial |
$45,846.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46,442.00
|
| Rate for Payer: Cash Price |
$29,770.52
|
| Rate for Payer: Cigna Commercial |
$49,419.05
|
| Rate for Payer: First Health Commercial |
$56,563.98
|
| Rate for Payer: Humana Commercial |
$50,609.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$48,823.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$43,941.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,862.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$52,396.11
|
| Rate for Payer: Ohio Health Group HMO |
$44,655.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47,632.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51,800.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41,083.31
|
| Rate for Payer: PHCS Commercial |
$57,159.39
|
| Rate for Payer: United Healthcare All Payer |
$52,396.11
|
|
|
LIDEX CREAM 0.05% 15 GM
|
Facility
|
OP
|
$12.64
|
|
|
Service Code
|
NDC 51672125401
|
| Hospital Charge Code |
25000870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$12.13 |
| Rate for Payer: Aetna Commercial |
$9.73
|
| Rate for Payer: Anthem Medicaid |
$4.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.86
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cigna Commercial |
$10.49
|
| Rate for Payer: First Health Commercial |
$12.01
|
| Rate for Payer: Humana Commercial |
$10.74
|
| Rate for Payer: Humana KY Medicaid |
$4.35
|
| Rate for Payer: Kentucky WC Medicaid |
$4.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.12
|
| Rate for Payer: Ohio Health Group HMO |
$9.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.72
|
| Rate for Payer: PHCS Commercial |
$12.13
|
| Rate for Payer: United Healthcare All Payer |
$11.12
|
|
|
LIDEX CREAM 0.05% 15 GM
|
Facility
|
IP
|
$12.64
|
|
|
Service Code
|
NDC 51672125401
|
| Hospital Charge Code |
25000870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$12.13 |
| Rate for Payer: Aetna Commercial |
$9.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.86
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cigna Commercial |
$10.49
|
| Rate for Payer: First Health Commercial |
$12.01
|
| Rate for Payer: Humana Commercial |
$10.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.12
|
| Rate for Payer: Ohio Health Group HMO |
$9.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.72
|
| Rate for Payer: PHCS Commercial |
$12.13
|
| Rate for Payer: United Healthcare All Payer |
$11.12
|
|
|
LIDEX(FLUOCINONIDE)0.05% 15GM
|
Facility
|
IP
|
$6.23
|
|
|
Service Code
|
NDC 51672126401
|
| Hospital Charge Code |
25000871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.86
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna Commercial |
$5.17
|
| Rate for Payer: First Health Commercial |
$5.92
|
| Rate for Payer: Humana Commercial |
$5.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.48
|
| Rate for Payer: Ohio Health Group HMO |
$4.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.30
|
| Rate for Payer: PHCS Commercial |
$5.98
|
| Rate for Payer: United Healthcare All Payer |
$5.48
|
|
|
LIDEX(FLUOCINONIDE)0.05% 15GM
|
Facility
|
OP
|
$6.23
|
|
|
Service Code
|
NDC 51672126401
|
| Hospital Charge Code |
25000871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Anthem Medicaid |
$2.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.86
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna Commercial |
$5.17
|
| Rate for Payer: First Health Commercial |
$5.92
|
| Rate for Payer: Humana Commercial |
$5.30
|
| Rate for Payer: Humana KY Medicaid |
$2.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.48
|
| Rate for Payer: Ohio Health Group HMO |
$4.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.30
|
| Rate for Payer: PHCS Commercial |
$5.98
|
| Rate for Payer: United Healthcare All Payer |
$5.48
|
|
|
LIDEX(FLUOCINONIDE)0.05% 30GM
|
Facility
|
IP
|
$9.83
|
|
|
Service Code
|
NDC 51672127902
|
| Hospital Charge Code |
25000872
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Aetna Commercial |
$7.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.67
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna Commercial |
$8.16
|
| Rate for Payer: First Health Commercial |
$9.34
|
| Rate for Payer: Humana Commercial |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.65
|
| Rate for Payer: Ohio Health Group HMO |
$7.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.78
|
| Rate for Payer: PHCS Commercial |
$9.44
|
| Rate for Payer: United Healthcare All Payer |
$8.65
|
|
|
LIDEX(FLUOCINONIDE)0.05% 30GM
|
Facility
|
OP
|
$9.83
|
|
|
Service Code
|
NDC 51672127902
|
| Hospital Charge Code |
25000872
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Aetna Commercial |
$7.57
|
| Rate for Payer: Anthem Medicaid |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.67
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna Commercial |
$8.16
|
| Rate for Payer: First Health Commercial |
$9.34
|
| Rate for Payer: Humana Commercial |
$8.36
|
| Rate for Payer: Humana KY Medicaid |
$3.38
|
| Rate for Payer: Kentucky WC Medicaid |
$3.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.65
|
| Rate for Payer: Ohio Health Group HMO |
$7.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.78
|
| Rate for Payer: PHCS Commercial |
$9.44
|
| Rate for Payer: United Healthcare All Payer |
$8.65
|
|
|
LIDEX (FLUOCINONIDE) .05%/60GM
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 51672127903
|
| Hospital Charge Code |
25003164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Aetna Commercial |
$4.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.23
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna Commercial |
$4.50
|
| Rate for Payer: First Health Commercial |
$5.15
|
| Rate for Payer: Humana Commercial |
$4.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.77
|
| Rate for Payer: Ohio Health Group HMO |
$4.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.74
|
| Rate for Payer: PHCS Commercial |
$5.20
|
| Rate for Payer: United Healthcare All Payer |
$4.77
|
|
|
LIDEX (FLUOCINONIDE) .05%/60GM
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 51672127903
|
| Hospital Charge Code |
25003164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Aetna Commercial |
$4.17
|
| Rate for Payer: Anthem Medicaid |
$1.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.23
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna Commercial |
$4.50
|
| Rate for Payer: First Health Commercial |
$5.15
|
| Rate for Payer: Humana Commercial |
$4.61
|
| Rate for Payer: Humana KY Medicaid |
$1.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.77
|
| Rate for Payer: Ohio Health Group HMO |
$4.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.74
|
| Rate for Payer: PHCS Commercial |
$5.20
|
| Rate for Payer: United Healthcare All Payer |
$4.77
|
|
|
LIDEX (LUOCINONIDE)0.05%G 15GM
|
Facility
|
OP
|
$12.07
|
|
|
Service Code
|
NDC 51672127901
|
| Hospital Charge Code |
25000868
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$9.29
|
| Rate for Payer: Anthem Medicaid |
$4.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.41
|
| Rate for Payer: Cash Price |
$6.04
|
| Rate for Payer: Cigna Commercial |
$10.02
|
| Rate for Payer: First Health Commercial |
$11.47
|
| Rate for Payer: Humana Commercial |
$10.26
|
| Rate for Payer: Humana KY Medicaid |
$4.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.62
|
| Rate for Payer: Ohio Health Group HMO |
$9.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.33
|
| Rate for Payer: PHCS Commercial |
$11.59
|
| Rate for Payer: United Healthcare All Payer |
$10.62
|
|
|
LIDEX (LUOCINONIDE)0.05%G 15GM
|
Facility
|
IP
|
$12.07
|
|
|
Service Code
|
NDC 51672127901
|
| Hospital Charge Code |
25000868
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$9.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.41
|
| Rate for Payer: Cash Price |
$6.04
|
| Rate for Payer: Cigna Commercial |
$10.02
|
| Rate for Payer: First Health Commercial |
$11.47
|
| Rate for Payer: Humana Commercial |
$10.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.62
|
| Rate for Payer: Ohio Health Group HMO |
$9.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.33
|
| Rate for Payer: PHCS Commercial |
$11.59
|
| Rate for Payer: United Healthcare All Payer |
$10.62
|
|
|
LIDO 1% + EPI 1:100 K VL(50ML)
|
Facility
|
IP
|
$79.98
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
636T0068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.78 |
| Rate for Payer: Aetna Commercial |
$61.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.38
|
| Rate for Payer: Cash Price |
$39.99
|
| Rate for Payer: Cigna Commercial |
$66.38
|
| Rate for Payer: First Health Commercial |
$75.98
|
| Rate for Payer: Humana Commercial |
$67.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.38
|
| Rate for Payer: Ohio Health Group HMO |
$59.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.19
|
| Rate for Payer: PHCS Commercial |
$76.78
|
| Rate for Payer: United Healthcare All Payer |
$70.38
|
|
|
LIDO 1% + EPI 1:100 K VL(50ML)
|
Facility
|
IP
|
$79.98
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.78 |
| Rate for Payer: Aetna Commercial |
$61.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.38
|
| Rate for Payer: Cash Price |
$39.99
|
| Rate for Payer: Cigna Commercial |
$66.38
|
| Rate for Payer: First Health Commercial |
$75.98
|
| Rate for Payer: Humana Commercial |
$67.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.38
|
| Rate for Payer: Ohio Health Group HMO |
$59.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.19
|
| Rate for Payer: PHCS Commercial |
$76.78
|
| Rate for Payer: United Healthcare All Payer |
$70.38
|
|
|
LIDO 1% + EPI 1:100 K VL(50ML)
|
Professional
|
Both
|
$79.98
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.99 |
| Max. Negotiated Rate |
$55.99 |
| Rate for Payer: Cash Price |
$39.99
|
| Rate for Payer: Multiplan PHCS |
$47.99
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.99
|
| Rate for Payer: UHCCP Medicaid |
$27.99
|
|
|
LIDO 1% + EPI 1:100 K VL(50ML)
|
Facility
|
OP
|
$79.98
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
636T0068
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.78 |
| Rate for Payer: Aetna Commercial |
$61.58
|
| Rate for Payer: Anthem Medicaid |
$27.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.38
|
| Rate for Payer: Cash Price |
$39.99
|
| Rate for Payer: Cigna Commercial |
$66.38
|
| Rate for Payer: First Health Commercial |
$75.98
|
| Rate for Payer: Humana Commercial |
$67.98
|
| Rate for Payer: Humana KY Medicaid |
$27.51
|
| Rate for Payer: Kentucky WC Medicaid |
$27.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.38
|
| Rate for Payer: Ohio Health Group HMO |
$59.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.19
|
| Rate for Payer: PHCS Commercial |
$76.78
|
| Rate for Payer: United Healthcare All Payer |
$70.38
|
|
|
LIDO 1% + EPI 1:100 K VL(50ML)
|
Facility
|
IP
|
$79.98
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25002461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.78 |
| Rate for Payer: Aetna Commercial |
$61.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.38
|
| Rate for Payer: Cash Price |
$39.99
|
| Rate for Payer: Cigna Commercial |
$66.38
|
| Rate for Payer: First Health Commercial |
$75.98
|
| Rate for Payer: Humana Commercial |
$67.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.38
|
| Rate for Payer: Ohio Health Group HMO |
$59.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.19
|
| Rate for Payer: PHCS Commercial |
$76.78
|
| Rate for Payer: United Healthcare All Payer |
$70.38
|
|
