|
LIDOCAINE 1% PF VIAL (2mL)
|
Facility
|
IP
|
$78.22
|
|
| Hospital Charge Code |
63600103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.47 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna Commercial |
$60.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.01
|
| Rate for Payer: Cash Price |
$39.11
|
| Rate for Payer: Cigna Commercial |
$64.92
|
| Rate for Payer: First Health Commercial |
$74.31
|
| Rate for Payer: Humana Commercial |
$66.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.83
|
| Rate for Payer: Ohio Health Group HMO |
$58.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.97
|
| Rate for Payer: PHCS Commercial |
$75.09
|
| Rate for Payer: United Healthcare All Payer |
$68.83
|
|
|
LIDOCAINE 1% PF VIAL (2mL)
|
Facility
|
OP
|
$78.22
|
|
| Hospital Charge Code |
63600103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.47 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna Commercial |
$60.23
|
| Rate for Payer: Anthem Medicaid |
$26.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.01
|
| Rate for Payer: Cash Price |
$39.11
|
| Rate for Payer: Cigna Commercial |
$64.92
|
| Rate for Payer: First Health Commercial |
$74.31
|
| Rate for Payer: Humana Commercial |
$66.49
|
| Rate for Payer: Humana KY Medicaid |
$26.90
|
| Rate for Payer: Kentucky WC Medicaid |
$27.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.83
|
| Rate for Payer: Ohio Health Group HMO |
$58.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.97
|
| Rate for Payer: PHCS Commercial |
$75.09
|
| Rate for Payer: United Healthcare All Payer |
$68.83
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Facility
|
IP
|
$79.93
|
|
| Hospital Charge Code |
63600102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$61.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.35
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cigna Commercial |
$66.34
|
| Rate for Payer: First Health Commercial |
$75.93
|
| Rate for Payer: Humana Commercial |
$67.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.34
|
| Rate for Payer: Ohio Health Group HMO |
$59.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.15
|
| Rate for Payer: PHCS Commercial |
$76.73
|
| Rate for Payer: United Healthcare All Payer |
$70.34
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Facility
|
OP
|
$79.93
|
|
| Hospital Charge Code |
63600102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$61.55
|
| Rate for Payer: Anthem Medicaid |
$27.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.35
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cigna Commercial |
$66.34
|
| Rate for Payer: First Health Commercial |
$75.93
|
| Rate for Payer: Humana Commercial |
$67.94
|
| Rate for Payer: Humana KY Medicaid |
$27.49
|
| Rate for Payer: Kentucky WC Medicaid |
$27.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.34
|
| Rate for Payer: Ohio Health Group HMO |
$59.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.15
|
| Rate for Payer: PHCS Commercial |
$76.73
|
| Rate for Payer: United Healthcare All Payer |
$70.34
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Facility
|
OP
|
$79.93
|
|
| Hospital Charge Code |
636T0102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$61.55
|
| Rate for Payer: Anthem Medicaid |
$27.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.35
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cigna Commercial |
$66.34
|
| Rate for Payer: First Health Commercial |
$75.93
|
| Rate for Payer: Humana Commercial |
$67.94
|
| Rate for Payer: Humana KY Medicaid |
$27.49
|
| Rate for Payer: Kentucky WC Medicaid |
$27.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.34
|
| Rate for Payer: Ohio Health Group HMO |
$59.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.15
|
| Rate for Payer: PHCS Commercial |
$76.73
|
| Rate for Payer: United Healthcare All Payer |
$70.34
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Facility
|
IP
|
$79.93
|
|
| Hospital Charge Code |
636T0102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$61.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.35
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cigna Commercial |
$66.34
|
| Rate for Payer: First Health Commercial |
$75.93
|
| Rate for Payer: Humana Commercial |
$67.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.34
|
| Rate for Payer: Ohio Health Group HMO |
$59.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.15
|
| Rate for Payer: PHCS Commercial |
$76.73
|
| Rate for Payer: United Healthcare All Payer |
$70.34
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Facility
|
OP
|
$79.93
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$61.55
|
| Rate for Payer: Anthem Medicaid |
$27.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.35
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cigna Commercial |
$66.34
|
| Rate for Payer: First Health Commercial |
$75.93
|
| Rate for Payer: Humana Commercial |
$67.94
|
| Rate for Payer: Humana KY Medicaid |
$27.49
|
| Rate for Payer: Kentucky WC Medicaid |
$27.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.34
|
| Rate for Payer: Ohio Health Group HMO |
$59.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.15
|
| Rate for Payer: PHCS Commercial |
$76.73
|
| Rate for Payer: United Healthcare All Payer |
$70.34
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Facility
|
IP
|
$79.93
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.98 |
| Max. Negotiated Rate |
$76.73 |
| Rate for Payer: Aetna Commercial |
$61.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.35
|
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Cigna Commercial |
$66.34
|
| Rate for Payer: First Health Commercial |
$75.93
|
| Rate for Payer: Humana Commercial |
$67.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.34
|
| Rate for Payer: Ohio Health Group HMO |
$59.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.15
|
| Rate for Payer: PHCS Commercial |
$76.73
|
| Rate for Payer: United Healthcare All Payer |
$70.34
|
|
|
LIDOCAINE 1% PF VIAL (5mL)
|
Professional
|
Both
|
$79.93
|
|
| Hospital Charge Code |
63600102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.98 |
| Max. Negotiated Rate |
$55.95 |
| Rate for Payer: Cash Price |
$39.97
|
| Rate for Payer: Multiplan PHCS |
$47.96
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.95
|
| Rate for Payer: UHCCP Medicaid |
$27.98
|
|
|
LIDOCAINE 1% TEARTO 300MG/10ML
|
Facility
|
IP
|
$79.27
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.78 |
| Max. Negotiated Rate |
$76.10 |
| Rate for Payer: Aetna Commercial |
$61.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Cash Price |
$39.63
|
| Rate for Payer: Cigna Commercial |
$65.79
|
| Rate for Payer: First Health Commercial |
$75.31
|
| Rate for Payer: Humana Commercial |
$67.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.76
|
| Rate for Payer: Ohio Health Group HMO |
$59.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.70
|
| Rate for Payer: PHCS Commercial |
$76.10
|
| Rate for Payer: United Healthcare All Payer |
$69.76
|
|
|
LIDOCAINE 1% TEARTO 300MG/10ML
|
Facility
|
OP
|
$79.27
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.78 |
| Max. Negotiated Rate |
$76.10 |
| Rate for Payer: Aetna Commercial |
$61.04
|
| Rate for Payer: Anthem Medicaid |
$27.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.83
|
| Rate for Payer: Cash Price |
$39.63
|
| Rate for Payer: Cigna Commercial |
$65.79
|
| Rate for Payer: First Health Commercial |
$75.31
|
| Rate for Payer: Humana Commercial |
$67.38
|
| Rate for Payer: Humana KY Medicaid |
$27.26
|
| Rate for Payer: Kentucky WC Medicaid |
$27.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.76
|
| Rate for Payer: Ohio Health Group HMO |
$59.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.70
|
| Rate for Payer: PHCS Commercial |
$76.10
|
| Rate for Payer: United Healthcare All Payer |
$69.76
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Facility
|
IP
|
$78.44
|
|
|
Service Code
|
NDC 63323020103
|
| Hospital Charge Code |
25003166
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna Commercial |
$60.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.18
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna Commercial |
$65.11
|
| Rate for Payer: First Health Commercial |
$74.52
|
| Rate for Payer: Humana Commercial |
$66.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.03
|
| Rate for Payer: Ohio Health Group HMO |
$58.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.12
|
| Rate for Payer: PHCS Commercial |
$75.30
|
| Rate for Payer: United Healthcare All Payer |
$69.03
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Facility
|
OP
|
$78.44
|
|
| Hospital Charge Code |
63600088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna Commercial |
$60.40
|
| Rate for Payer: Anthem Medicaid |
$26.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.18
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna Commercial |
$65.11
|
| Rate for Payer: First Health Commercial |
$74.52
|
| Rate for Payer: Humana Commercial |
$66.67
|
| Rate for Payer: Humana KY Medicaid |
$26.98
|
| Rate for Payer: Kentucky WC Medicaid |
$27.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.03
|
| Rate for Payer: Ohio Health Group HMO |
$58.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.12
|
| Rate for Payer: PHCS Commercial |
$75.30
|
| Rate for Payer: United Healthcare All Payer |
$69.03
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Facility
|
OP
|
$78.44
|
|
| Hospital Charge Code |
636T0088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna Commercial |
$60.40
|
| Rate for Payer: Anthem Medicaid |
$26.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.18
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna Commercial |
$65.11
|
| Rate for Payer: First Health Commercial |
$74.52
|
| Rate for Payer: Humana Commercial |
$66.67
|
| Rate for Payer: Humana KY Medicaid |
$26.98
|
| Rate for Payer: Kentucky WC Medicaid |
$27.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.03
|
| Rate for Payer: Ohio Health Group HMO |
$58.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.12
|
| Rate for Payer: PHCS Commercial |
$75.30
|
| Rate for Payer: United Healthcare All Payer |
$69.03
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Facility
|
IP
|
$78.44
|
|
| Hospital Charge Code |
636T0088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna Commercial |
$60.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.18
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna Commercial |
$65.11
|
| Rate for Payer: First Health Commercial |
$74.52
|
| Rate for Payer: Humana Commercial |
$66.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.03
|
| Rate for Payer: Ohio Health Group HMO |
$58.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.12
|
| Rate for Payer: PHCS Commercial |
$75.30
|
| Rate for Payer: United Healthcare All Payer |
$69.03
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Facility
|
OP
|
$78.44
|
|
|
Service Code
|
NDC 63323020103
|
| Hospital Charge Code |
25003166
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna Commercial |
$60.40
|
| Rate for Payer: Anthem Medicaid |
$26.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.18
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna Commercial |
$65.11
|
| Rate for Payer: First Health Commercial |
$74.52
|
| Rate for Payer: Humana Commercial |
$66.67
|
| Rate for Payer: Humana KY Medicaid |
$26.98
|
| Rate for Payer: Kentucky WC Medicaid |
$27.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.03
|
| Rate for Payer: Ohio Health Group HMO |
$58.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.12
|
| Rate for Payer: PHCS Commercial |
$75.30
|
| Rate for Payer: United Healthcare All Payer |
$69.03
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Professional
|
Both
|
$78.44
|
|
| Hospital Charge Code |
63600088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$54.91 |
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Multiplan PHCS |
$47.06
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.91
|
| Rate for Payer: UHCCP Medicaid |
$27.45
|
|
|
LIDOCAINE 1% VIAL (10ML)
|
Facility
|
IP
|
$78.44
|
|
| Hospital Charge Code |
63600088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna Commercial |
$60.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.18
|
| Rate for Payer: Cash Price |
$39.22
|
| Rate for Payer: Cigna Commercial |
$65.11
|
| Rate for Payer: First Health Commercial |
$74.52
|
| Rate for Payer: Humana Commercial |
$66.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.03
|
| Rate for Payer: Ohio Health Group HMO |
$58.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.12
|
| Rate for Payer: PHCS Commercial |
$75.30
|
| Rate for Payer: United Healthcare All Payer |
$69.03
|
|
|
LIDOCAINE 2% JELLY W/INJ 6ML
|
Facility
|
OP
|
$22.95
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
25003169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna Commercial |
$17.67
|
| Rate for Payer: Anthem Medicaid |
$7.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.90
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cigna Commercial |
$19.05
|
| Rate for Payer: First Health Commercial |
$21.80
|
| Rate for Payer: Humana Commercial |
$19.51
|
| Rate for Payer: Humana KY Medicaid |
$7.89
|
| Rate for Payer: Kentucky WC Medicaid |
$7.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.20
|
| Rate for Payer: Ohio Health Group HMO |
$17.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.84
|
| Rate for Payer: PHCS Commercial |
$22.03
|
| Rate for Payer: United Healthcare All Payer |
$20.20
|
|
|
LIDOCAINE 2% JELLY W/INJ 6ML
|
Facility
|
IP
|
$22.95
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
25003169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna Commercial |
$17.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.90
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cigna Commercial |
$19.05
|
| Rate for Payer: First Health Commercial |
$21.80
|
| Rate for Payer: Humana Commercial |
$19.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.20
|
| Rate for Payer: Ohio Health Group HMO |
$17.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.84
|
| Rate for Payer: PHCS Commercial |
$22.03
|
| Rate for Payer: United Healthcare All Payer |
$20.20
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
IP
|
$78.34
|
|
| Hospital Charge Code |
636T0105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.05
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
OP
|
$78.34
|
|
| Hospital Charge Code |
636T0105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem Medicaid |
$26.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Humana KY Medicaid |
$26.94
|
| Rate for Payer: Kentucky WC Medicaid |
$27.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.05
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
OP
|
$78.34
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem Medicaid |
$26.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Humana KY Medicaid |
$26.94
|
| Rate for Payer: Kentucky WC Medicaid |
$27.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.05
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
OP
|
$78.34
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
63600105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem Medicaid |
$26.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Humana KY Medicaid |
$26.94
|
| Rate for Payer: Kentucky WC Medicaid |
$27.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.05
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
IP
|
$78.34
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
63600105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$75.21 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.11
|
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Cigna Commercial |
$65.02
|
| Rate for Payer: First Health Commercial |
$74.42
|
| Rate for Payer: Humana Commercial |
$66.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.94
|
| Rate for Payer: Ohio Health Group HMO |
$58.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.05
|
| Rate for Payer: PHCS Commercial |
$75.21
|
| Rate for Payer: United Healthcare All Payer |
$68.94
|
|
