|
LINZESS 290 MCG CAPSULE
|
Facility
|
IP
|
$35.03
|
|
|
Service Code
|
NDC 456120230
|
| Hospital Charge Code |
25000878
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.63 |
| Rate for Payer: Aetna Commercial |
$26.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.32
|
| Rate for Payer: Cash Price |
$17.52
|
| Rate for Payer: Cigna Commercial |
$29.07
|
| Rate for Payer: First Health Commercial |
$33.28
|
| Rate for Payer: Humana Commercial |
$29.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.83
|
| Rate for Payer: Ohio Health Group HMO |
$26.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.86
|
| Rate for Payer: PHCS Commercial |
$33.63
|
| Rate for Payer: United Healthcare All Payer |
$30.83
|
|
|
LINZESS 72MCG CAPSULE
|
Facility
|
OP
|
$35.03
|
|
|
Service Code
|
NDC 456120330
|
| Hospital Charge Code |
25003180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.63 |
| Rate for Payer: Aetna Commercial |
$26.97
|
| Rate for Payer: Anthem Medicaid |
$12.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.32
|
| Rate for Payer: Cash Price |
$17.52
|
| Rate for Payer: Cigna Commercial |
$29.07
|
| Rate for Payer: First Health Commercial |
$33.28
|
| Rate for Payer: Humana Commercial |
$29.78
|
| Rate for Payer: Humana KY Medicaid |
$12.05
|
| Rate for Payer: Kentucky WC Medicaid |
$12.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.83
|
| Rate for Payer: Ohio Health Group HMO |
$26.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.86
|
| Rate for Payer: PHCS Commercial |
$33.63
|
| Rate for Payer: United Healthcare All Payer |
$30.83
|
|
|
LINZESS 72MCG CAPSULE
|
Facility
|
IP
|
$35.03
|
|
|
Service Code
|
NDC 456120330
|
| Hospital Charge Code |
25003180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.63 |
| Rate for Payer: Aetna Commercial |
$26.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.32
|
| Rate for Payer: Cash Price |
$17.52
|
| Rate for Payer: Cigna Commercial |
$29.07
|
| Rate for Payer: First Health Commercial |
$33.28
|
| Rate for Payer: Humana Commercial |
$29.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.83
|
| Rate for Payer: Ohio Health Group HMO |
$26.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.86
|
| Rate for Payer: PHCS Commercial |
$33.63
|
| Rate for Payer: United Healthcare All Payer |
$30.83
|
|
|
LIORESAL (BACLOFEN) 10MG/1TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 904647561
|
| Hospital Charge Code |
25000879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
| Rate for Payer: Aetna Commercial |
$3.56
|
|
|
LIORESAL (BACLOFEN) 10MG/1TAB
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 904647561
|
| Hospital Charge Code |
25000879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
Lip and Full Chin Lsr Hair Rem
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200180
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
LIPASE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 83690
|
| Hospital Charge Code |
30000443
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$6.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.89
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$6.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.89
|
| Rate for Payer: Kentucky WC Medicaid |
$6.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.32
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
LIPASE
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
30000443
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Anthem Medicaid |
$6.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.89
|
| Rate for Payer: Humana KY Medicaid |
$6.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.89
|
| Rate for Payer: Kentucky WC Medicaid |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.03
|
|
|
LIPASE
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
CPT 83690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Anthem Medicaid |
$6.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.89
|
| Rate for Payer: Humana KY Medicaid |
$6.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.89
|
| Rate for Payer: Kentucky WC Medicaid |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.03
|
|
|
LIPASE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 83690
|
| Hospital Charge Code |
30000443
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.32
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
Lip Chin LsrHairRem-PP#1 50%
|
Professional
|
Both
|
$319.00
|
|
| Hospital Charge Code |
22200344
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$319.00
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$223.30
|
| Rate for Payer: UHCCP Medicaid |
$111.65
|
|
|
Lip Chin LsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$159.00
|
|
| Hospital Charge Code |
22200460
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$159.00
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Multiplan PHCS |
$95.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$111.30
|
| Rate for Payer: UHCCP Medicaid |
$55.65
|
|
|
LIPID PANEL
|
Professional
|
Both
|
$52.00
|
|
|
Service Code
|
HCPCS 80061
|
| Hospital Charge Code |
30000011
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$52.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: Healthspan PPO |
$12.56
|
| Rate for Payer: Multiplan PHCS |
$31.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$36.40
|
| Rate for Payer: UHCCP Medicaid |
$18.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$8.03
|
|
|
LIPID PANEL
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
HCPCS 80061
|
| Hospital Charge Code |
30000011
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$49.92 |
| Rate for Payer: Aetna Commercial |
$40.04
|
| Rate for Payer: Anthem Medicaid |
$13.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.39
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.16
|
| Rate for Payer: First Health Commercial |
$49.40
|
| Rate for Payer: Humana Commercial |
$44.20
|
| Rate for Payer: Humana KY Medicaid |
$13.39
|
| Rate for Payer: Humana Medicare Advantage |
$13.39
|
| Rate for Payer: Kentucky WC Medicaid |
$13.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.76
|
| Rate for Payer: Ohio Health Group HMO |
$39.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.12
|
| Rate for Payer: PHCS Commercial |
$49.92
|
| Rate for Payer: United Healthcare All Payer |
$45.76
|
|
|
LIPID PANEL
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
HCPCS 80061
|
| Hospital Charge Code |
30000011
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$49.92 |
| Rate for Payer: Aetna Commercial |
$40.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.76
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.16
|
| Rate for Payer: First Health Commercial |
$49.40
|
| Rate for Payer: Humana Commercial |
$44.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.76
|
| Rate for Payer: Ohio Health Group HMO |
$39.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.12
|
| Rate for Payer: PHCS Commercial |
$49.92
|
| Rate for Payer: United Healthcare All Payer |
$45.76
|
|
|
LIPITOR 20MG EQUIV TABLET
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 68084009801
|
| Hospital Charge Code |
25000882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
LIPITOR 20MG EQUIV TABLET
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 68084009801
|
| Hospital Charge Code |
25000882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
LIPITOR 40MG TABLET
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 68084009901
|
| Hospital Charge Code |
25000883
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
LIPITOR 40MG TABLET
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 68084009901
|
| Hospital Charge Code |
25000883
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
LIPITOR (ATORVAS CAL) 80 MGTAB
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
NDC 68084059025
|
| Hospital Charge Code |
25000880
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
LIPITOR (ATORVAS CAL) 80 MGTAB
|
Facility
|
OP
|
$4.88
|
|
|
Service Code
|
NDC 68084059025
|
| Hospital Charge Code |
25000880
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
LIPITOR (ATROVASTATI 10MG/1TAB
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 68084009701
|
| Hospital Charge Code |
25000881
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
LIPITOR (ATROVASTATI 10MG/1TAB
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 68084009701
|
| Hospital Charge Code |
25000881
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
LIPO (ANY W/COSMO SURG)
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200097
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
LIPO (ANY W/COSMO SURG)-80
|
Professional
|
Both
|
$300.00
|
|
| Hospital Charge Code |
22200387
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
|
