|
LIDOCAINE 2% MDV 20mL
|
Professional
|
Both
|
$78.34
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
63600105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.42 |
| Max. Negotiated Rate |
$54.84 |
| Rate for Payer: Cash Price |
$39.17
|
| Rate for Payer: Multiplan PHCS |
$47.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.84
|
| Rate for Payer: UHCCP Medicaid |
$27.42
|
|
|
LIDOCAINE 2% MDV 20mL
|
Facility
|
IP
|
$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 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% PF 2ML VIAL
|
Facility
|
IP
|
$78.93
|
|
|
Service Code
|
NDC 63323049527
|
| Hospital Charge Code |
25004085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$75.77 |
| Rate for Payer: Aetna Commercial |
$60.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.57
|
| Rate for Payer: Cash Price |
$39.47
|
| Rate for Payer: Cigna Commercial |
$65.51
|
| Rate for Payer: First Health Commercial |
$74.98
|
| Rate for Payer: Humana Commercial |
$67.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.46
|
| Rate for Payer: Ohio Health Group HMO |
$59.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.46
|
| Rate for Payer: PHCS Commercial |
$75.77
|
| Rate for Payer: United Healthcare All Payer |
$69.46
|
|
|
LIDOCAINE 2% PF 2ML VIAL
|
Facility
|
OP
|
$78.93
|
|
|
Service Code
|
NDC 63323049527
|
| Hospital Charge Code |
25004085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$75.77 |
| Rate for Payer: Aetna Commercial |
$60.78
|
| Rate for Payer: Anthem Medicaid |
$27.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.57
|
| Rate for Payer: Cash Price |
$39.47
|
| Rate for Payer: Cigna Commercial |
$65.51
|
| Rate for Payer: First Health Commercial |
$74.98
|
| Rate for Payer: Humana Commercial |
$67.09
|
| Rate for Payer: Humana KY Medicaid |
$27.14
|
| Rate for Payer: Kentucky WC Medicaid |
$27.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.46
|
| Rate for Payer: Ohio Health Group HMO |
$59.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.46
|
| Rate for Payer: PHCS Commercial |
$75.77
|
| Rate for Payer: United Healthcare All Payer |
$69.46
|
|
|
LIDOCAINE 2% VISCOUS 5ML
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
25003171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem Medicaid |
$9.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Humana KY Medicaid |
$9.63
|
| Rate for Payer: Kentucky WC Medicaid |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.32
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
LIDOCAINE 2% VISCOUS 5ML
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
25003171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.32
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
LIDOCAINE2%VISCOUS SOL'N(15ML)
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem Medicaid |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Humana KY Medicaid |
$3.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.66
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
LIDOCAINE2%VISCOUS SOL'N(15ML)
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.26 |
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$8.01
|
| Rate for Payer: First Health Commercial |
$9.17
|
| Rate for Payer: Humana Commercial |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.49
|
| Rate for Payer: Ohio Health Group HMO |
$7.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.66
|
| Rate for Payer: PHCS Commercial |
$9.26
|
| Rate for Payer: United Healthcare All Payer |
$8.49
|
|
|
LIDOCAINE 3% 1 ML SWAB
|
Facility
|
OP
|
$10.50
|
|
|
Service Code
|
NDC 35781030105
|
| Hospital Charge Code |
25003969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Anthem Medicaid |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.19
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna Commercial |
$8.71
|
| Rate for Payer: First Health Commercial |
$9.97
|
| Rate for Payer: Humana Commercial |
$8.93
|
| Rate for Payer: Humana KY Medicaid |
$3.61
|
| Rate for Payer: Kentucky WC Medicaid |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.25
|
| Rate for Payer: PHCS Commercial |
$10.08
|
| Rate for Payer: United Healthcare All Payer |
$9.24
|
|
|
LIDOCAINE 3% 1 ML SWAB
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
NDC 35781030105
|
| Hospital Charge Code |
25003969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.19
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna Commercial |
$8.71
|
| Rate for Payer: First Health Commercial |
$9.97
|
| Rate for Payer: Humana Commercial |
$8.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.25
|
| Rate for Payer: PHCS Commercial |
$10.08
|
| Rate for Payer: United Healthcare All Payer |
$9.24
|
|
|
LIDOCAINE 4% 1 ML SPRAY
|
Facility
|
OP
|
$9.08
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
25003174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$8.72 |
| Rate for Payer: Aetna Commercial |
$6.99
|
| Rate for Payer: Anthem Medicaid |
$3.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Cash Price |
$4.54
|
| Rate for Payer: Cigna Commercial |
$7.54
|
| Rate for Payer: First Health Commercial |
$8.63
|
| Rate for Payer: Humana Commercial |
$7.72
|
| Rate for Payer: Humana KY Medicaid |
$3.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.99
|
| Rate for Payer: Ohio Health Group HMO |
$6.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.27
|
| Rate for Payer: PHCS Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Payer |
$7.99
|
|
|
LIDOCAINE 4% 1 ML SPRAY
|
Facility
|
IP
|
$9.08
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
25003174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$8.72 |
| Rate for Payer: Aetna Commercial |
$6.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Cash Price |
$4.54
|
| Rate for Payer: Cigna Commercial |
$7.54
|
| Rate for Payer: First Health Commercial |
$8.63
|
| Rate for Payer: Humana Commercial |
$7.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.99
|
| Rate for Payer: Ohio Health Group HMO |
$6.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.27
|
| Rate for Payer: PHCS Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Payer |
$7.99
|
|
|
LIDOCAINE 4% 5gm Crm KIT
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
25000604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.86
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.53
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
LIDOCAINE 4% 5gm Crm KIT
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
25000604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.86
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Humana KY Medicaid |
$12.72
|
| Rate for Payer: Kentucky WC Medicaid |
$12.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.53
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
Lidocaine 5% (30gm)
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
NDC 51672302002
|
| Hospital Charge Code |
25004098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
Lidocaine 5% (30gm)
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
NDC 51672302002
|
| Hospital Charge Code |
25004098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem Medicaid |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Humana KY Medicaid |
$62.25
|
| Rate for Payer: Kentucky WC Medicaid |
$62.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
LIDOCAINE+EPI 2%-1:200K PF 20
|
Facility
|
OP
|
$112.05
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem Medicaid |
$38.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Humana KY Medicaid |
$38.53
|
| Rate for Payer: Kentucky WC Medicaid |
$38.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.31
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
|
LIDOCAINE+EPI 2%-1:200K PF 20
|
Facility
|
IP
|
$112.05
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.31
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
|
LIDODERM (LIDOCAINE) PATCH 5EA
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 591352530
|
| Hospital Charge Code |
25000874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
LIDODERM (LIDOCAINE) PATCH 5EA
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 591352530
|
| Hospital Charge Code |
25000874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
LIDO+EPI 0.5%-1:200K 50ML MDV
|
Facility
|
IP
|
$79.86
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25004232
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.96 |
| Max. Negotiated Rate |
$76.67 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.29
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna Commercial |
$66.28
|
| Rate for Payer: First Health Commercial |
$75.87
|
| Rate for Payer: Humana Commercial |
$67.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.28
|
| Rate for Payer: Ohio Health Group HMO |
$59.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.10
|
| Rate for Payer: PHCS Commercial |
$76.67
|
| Rate for Payer: United Healthcare All Payer |
$70.28
|
|
|
LIDO+EPI 0.5%-1:200K 50ML MDV
|
Facility
|
OP
|
$79.86
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25004232
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.96 |
| Max. Negotiated Rate |
$76.67 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: Anthem Medicaid |
$27.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.29
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna Commercial |
$66.28
|
| Rate for Payer: First Health Commercial |
$75.87
|
| Rate for Payer: Humana Commercial |
$67.88
|
| Rate for Payer: Humana KY Medicaid |
$27.46
|
| Rate for Payer: Kentucky WC Medicaid |
$27.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.28
|
| Rate for Payer: Ohio Health Group HMO |
$59.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.10
|
| Rate for Payer: PHCS Commercial |
$76.67
|
| Rate for Payer: United Healthcare All Payer |
$70.28
|
|
|
LIDO+EPI 1%-1:100K MDV 30 VIAL
|
Facility
|
IP
|
$112.67
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003959
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna Commercial |
$86.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.88
|
| Rate for Payer: Cash Price |
$56.34
|
| Rate for Payer: Cigna Commercial |
$93.52
|
| Rate for Payer: First Health Commercial |
$107.04
|
| Rate for Payer: Humana Commercial |
$95.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.15
|
| Rate for Payer: Ohio Health Group HMO |
$84.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.74
|
| Rate for Payer: PHCS Commercial |
$108.16
|
| Rate for Payer: United Healthcare All Payer |
$99.15
|
|
|
LIDO+EPI 1%-1:100K MDV 30 VIAL
|
Facility
|
OP
|
$112.67
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003959
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna Commercial |
$86.76
|
| Rate for Payer: Anthem Medicaid |
$38.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.88
|
| Rate for Payer: Cash Price |
$56.34
|
| Rate for Payer: Cigna Commercial |
$93.52
|
| Rate for Payer: First Health Commercial |
$107.04
|
| Rate for Payer: Humana Commercial |
$95.77
|
| Rate for Payer: Humana KY Medicaid |
$38.75
|
| Rate for Payer: Kentucky WC Medicaid |
$39.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.15
|
| Rate for Payer: Ohio Health Group HMO |
$84.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.74
|
| Rate for Payer: PHCS Commercial |
$108.16
|
| Rate for Payer: United Healthcare All Payer |
$99.15
|
|
|
LIDO+EPI 2%-1:100K MDV 30ML VL
|
Facility
|
OP
|
$80.39
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25004024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem Medicaid |
$27.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.70
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.72
|
| Rate for Payer: First Health Commercial |
$76.37
|
| Rate for Payer: Humana Commercial |
$68.33
|
| Rate for Payer: Humana KY Medicaid |
$27.65
|
| Rate for Payer: Kentucky WC Medicaid |
$27.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.74
|
| Rate for Payer: Ohio Health Group HMO |
$60.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
