|
LOCATOR PLUS 1281/52
|
Facility
|
IP
|
$1,822.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$236.92 |
| Max. Negotiated Rate |
$1,749.60 |
| Rate for Payer: Aetna Commercial |
$1,403.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,421.55
|
| Rate for Payer: Cash Price |
$911.25
|
| Rate for Payer: Cigna Commercial |
$1,512.68
|
| Rate for Payer: First Health Commercial |
$1,731.38
|
| Rate for Payer: Humana Commercial |
$1,549.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,494.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,345.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,603.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,366.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$364.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$236.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$564.98
|
| Rate for Payer: PHCS Commercial |
$1,749.60
|
| Rate for Payer: United Healthcare All Payer |
$1,603.80
|
|
|
LOCKING SCREW 3.5*12MM
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*12MM
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*18MM
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*18MM
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*22
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*22
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*28MM
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCKING SCREW 3.5*28MM
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
LOCK WIRE GUIDE JIG
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LOCK WIRE GUIDE JIG
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LODINE (ETODOLAC) 2 200MG/1CAP
|
Facility
|
OP
|
$9.08
|
|
|
Service Code
|
NDC 60505003901
|
| Hospital Charge Code |
25000894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| 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 |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Payer |
$7.99
|
|
|
LODINE (ETODOLAC) 2 200MG/1CAP
|
Facility
|
IP
|
$9.08
|
|
|
Service Code
|
NDC 60505003901
|
| Hospital Charge Code |
25000894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| 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 |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Payer |
$7.99
|
|
|
LODINE (ETODOLAC) 3 300MG/1CAP
|
Facility
|
OP
|
$9.29
|
|
|
Service Code
|
NDC 51672401701
|
| Hospital Charge Code |
25000895
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.92 |
| Rate for Payer: Humana Commercial |
$7.90
|
| Rate for Payer: Humana KY Medicaid |
$3.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$8.92
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
| Rate for Payer: Aetna Commercial |
$7.15
|
| Rate for Payer: Anthem Medicaid |
$3.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.71
|
| Rate for Payer: First Health Commercial |
$8.83
|
|
|
LODINE (ETODOLAC) 3 300MG/1CAP
|
Facility
|
IP
|
$9.29
|
|
|
Service Code
|
NDC 51672401701
|
| Hospital Charge Code |
25000895
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.92 |
| Rate for Payer: Aetna Commercial |
$7.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.71
|
| Rate for Payer: First Health Commercial |
$8.83
|
| Rate for Payer: Humana Commercial |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$8.92
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
LODINE XL 600MG TABLET
|
Facility
|
IP
|
$10.62
|
|
|
Service Code
|
NDC 93111801
|
| Hospital Charge Code |
25000898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Aetna Commercial |
$8.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.28
|
| Rate for Payer: Cash Price |
$5.31
|
| Rate for Payer: Cigna Commercial |
$8.81
|
| Rate for Payer: First Health Commercial |
$10.09
|
| Rate for Payer: Humana Commercial |
$9.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.35
|
| Rate for Payer: Ohio Health Group HMO |
$7.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.29
|
| Rate for Payer: PHCS Commercial |
$10.20
|
| Rate for Payer: United Healthcare All Payer |
$9.35
|
|
|
LODINE XL 600MG TABLET
|
Facility
|
OP
|
$10.62
|
|
|
Service Code
|
NDC 93111801
|
| Hospital Charge Code |
25000898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Aetna Commercial |
$8.18
|
| Rate for Payer: Anthem Medicaid |
$3.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.28
|
| Rate for Payer: Cash Price |
$5.31
|
| Rate for Payer: Cigna Commercial |
$8.81
|
| Rate for Payer: First Health Commercial |
$10.09
|
| Rate for Payer: Humana Commercial |
$9.03
|
| Rate for Payer: Humana KY Medicaid |
$3.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.35
|
| Rate for Payer: Ohio Health Group HMO |
$7.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.29
|
| Rate for Payer: PHCS Commercial |
$10.20
|
| Rate for Payer: United Healthcare All Payer |
$9.35
|
|
|
LO-DO COMP TOM LUN CANC SCREEN
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS S8032
|
| Hospital Charge Code |
35000021
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem Medicaid |
$68.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Humana KY Medicaid |
$68.78
|
| Rate for Payer: Kentucky WC Medicaid |
$69.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
LO-DO COMP TOM LUN CANC SCREEN
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS S8032
|
| Hospital Charge Code |
35000021
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
LODOSYN 25MG TABLET
|
Facility
|
OP
|
$25.75
|
|
|
Service Code
|
NDC 43975022010
|
| Hospital Charge Code |
25000899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$24.72 |
| Rate for Payer: Aetna Commercial |
$19.83
|
| Rate for Payer: Anthem Medicaid |
$8.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.08
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna Commercial |
$21.37
|
| Rate for Payer: First Health Commercial |
$24.46
|
| Rate for Payer: Humana Commercial |
$21.89
|
| Rate for Payer: Humana KY Medicaid |
$8.86
|
| Rate for Payer: Kentucky WC Medicaid |
$8.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.66
|
| Rate for Payer: Ohio Health Group HMO |
$19.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.98
|
| Rate for Payer: PHCS Commercial |
$24.72
|
| Rate for Payer: United Healthcare All Payer |
$22.66
|
|
|
LODOSYN 25MG TABLET
|
Facility
|
IP
|
$25.75
|
|
|
Service Code
|
NDC 43975022010
|
| Hospital Charge Code |
25000899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$24.72 |
| Rate for Payer: Aetna Commercial |
$19.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.08
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cigna Commercial |
$21.37
|
| Rate for Payer: First Health Commercial |
$24.46
|
| Rate for Payer: Humana Commercial |
$21.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.66
|
| Rate for Payer: Ohio Health Group HMO |
$19.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.98
|
| Rate for Payer: PHCS Commercial |
$24.72
|
| Rate for Payer: United Healthcare All Payer |
$22.66
|
|
|
LOFIBRA 160 MG CAPSULE
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 42858066045
|
| Hospital Charge Code |
25003821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.19
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
|
|
LOFIBRA 160 MG CAPSULE
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 42858066045
|
| Hospital Charge Code |
25003821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: First Health Commercial |
$4.14
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.84
|
| Rate for Payer: Ohio Health Group HMO |
$3.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.19
|
| Rate for Payer: United Healthcare All Payer |
$3.84
|
|
|
LOKELMA 10GM POWDER PACKET
|
Facility
|
OP
|
$65.35
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$62.74 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Anthem Medicaid |
$22.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.97
|
| Rate for Payer: Cash Price |
$32.67
|
| Rate for Payer: Cigna Commercial |
$54.24
|
| Rate for Payer: First Health Commercial |
$62.08
|
| Rate for Payer: Humana Commercial |
$55.55
|
| Rate for Payer: Humana KY Medicaid |
$22.47
|
| Rate for Payer: Kentucky WC Medicaid |
$22.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.51
|
| Rate for Payer: Ohio Health Group HMO |
$49.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.26
|
| Rate for Payer: PHCS Commercial |
$62.74
|
| Rate for Payer: United Healthcare All Payer |
$57.51
|
|
|
LOKELMA 10GM POWDER PACKET
|
Facility
|
IP
|
$65.35
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$62.74 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.97
|
| Rate for Payer: Cash Price |
$32.67
|
| Rate for Payer: Cigna Commercial |
$54.24
|
| Rate for Payer: First Health Commercial |
$62.08
|
| Rate for Payer: Humana Commercial |
$55.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.51
|
| Rate for Payer: Ohio Health Group HMO |
$49.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.26
|
| Rate for Payer: PHCS Commercial |
$62.74
|
| Rate for Payer: United Healthcare All Payer |
$57.51
|
|
