|
LOPRESSOR (METOPROLO 25MG/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 62584026501
|
| Hospital Charge Code |
25000906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
LOPRESSOR (METOPROLO 50MG/1TAB
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 62584026601
|
| Hospital Charge Code |
25000907
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
LOPRESSOR (METOPROLO 50MG/1TAB
|
Facility
|
OP
|
$4.31
|
|
|
Service Code
|
NDC 62584026601
|
| Hospital Charge Code |
25000907
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
LOPRESSOR (METOPROLOL) 5MG/5ML
|
Facility
|
OP
|
$77.23
|
|
|
Service Code
|
NDC 409177805
|
| Hospital Charge Code |
25003691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$74.14 |
| Rate for Payer: Aetna Commercial |
$59.47
|
| Rate for Payer: Anthem Medicaid |
$26.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.24
|
| Rate for Payer: Cash Price |
$38.62
|
| Rate for Payer: Cigna Commercial |
$64.10
|
| Rate for Payer: First Health Commercial |
$73.37
|
| Rate for Payer: Humana Commercial |
$65.65
|
| Rate for Payer: Humana KY Medicaid |
$26.56
|
| Rate for Payer: Kentucky WC Medicaid |
$26.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.96
|
| Rate for Payer: Ohio Health Group HMO |
$57.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.94
|
| Rate for Payer: PHCS Commercial |
$74.14
|
| Rate for Payer: United Healthcare All Payer |
$67.96
|
|
|
LOPRESSOR (METOPROLOL) 5MG/5ML
|
Facility
|
IP
|
$77.23
|
|
|
Service Code
|
NDC 409177805
|
| Hospital Charge Code |
25003691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$74.14 |
| Rate for Payer: Aetna Commercial |
$59.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.24
|
| Rate for Payer: Cash Price |
$38.62
|
| Rate for Payer: Cigna Commercial |
$64.10
|
| Rate for Payer: First Health Commercial |
$73.37
|
| Rate for Payer: Humana Commercial |
$65.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.96
|
| Rate for Payer: Ohio Health Group HMO |
$57.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.94
|
| Rate for Payer: PHCS Commercial |
$74.14
|
| Rate for Payer: United Healthcare All Payer |
$67.96
|
|
|
LOPRESSOR(METOPROLOL) 5MG/5ML
|
Facility
|
OP
|
$77.23
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$74.14 |
| Rate for Payer: Aetna Commercial |
$59.47
|
| Rate for Payer: Anthem Medicaid |
$26.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.24
|
| Rate for Payer: Cash Price |
$38.62
|
| Rate for Payer: Cigna Commercial |
$64.10
|
| Rate for Payer: First Health Commercial |
$73.37
|
| Rate for Payer: Humana Commercial |
$65.65
|
| Rate for Payer: Humana KY Medicaid |
$26.56
|
| Rate for Payer: Kentucky WC Medicaid |
$26.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.96
|
| Rate for Payer: Ohio Health Group HMO |
$57.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.94
|
| Rate for Payer: PHCS Commercial |
$74.14
|
| Rate for Payer: United Healthcare All Payer |
$67.96
|
|
|
LOPRESSOR(METOPROLOL) 5MG/5ML
|
Facility
|
IP
|
$77.23
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$74.14 |
| Rate for Payer: Aetna Commercial |
$59.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.24
|
| Rate for Payer: Cash Price |
$38.62
|
| Rate for Payer: Cigna Commercial |
$64.10
|
| Rate for Payer: First Health Commercial |
$73.37
|
| Rate for Payer: Humana Commercial |
$65.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.96
|
| Rate for Payer: Ohio Health Group HMO |
$57.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.94
|
| Rate for Payer: PHCS Commercial |
$74.14
|
| Rate for Payer: United Healthcare All Payer |
$67.96
|
|
|
LOPROX 0.77% CREAM 30 GRAM
|
Facility
|
IP
|
$6.14
|
|
|
Service Code
|
NDC 51672131802
|
| Hospital Charge Code |
25000908
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.79
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.83
|
| Rate for Payer: Humana Commercial |
$5.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.40
|
| Rate for Payer: Ohio Health Group HMO |
$4.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.90
|
| Rate for Payer: PHCS Commercial |
$5.89
|
| Rate for Payer: United Healthcare All Payer |
$5.40
|
|
|
LOPROX 0.77% CREAM 30 GRAM
|
Facility
|
OP
|
$6.14
|
|
|
Service Code
|
NDC 51672131802
|
| Hospital Charge Code |
25000908
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Anthem Medicaid |
$2.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.79
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.83
|
| Rate for Payer: Humana Commercial |
$5.22
|
| Rate for Payer: Humana KY Medicaid |
$2.11
|
| Rate for Payer: Kentucky WC Medicaid |
$2.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.40
|
| Rate for Payer: Ohio Health Group HMO |
$4.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.90
|
| Rate for Payer: PHCS Commercial |
$5.89
|
| Rate for Payer: United Healthcare All Payer |
$5.40
|
|
|
LOPROX EQ 0.77% GEL 30 GRAM
|
Facility
|
OP
|
$10.20
|
|
|
Service Code
|
NDC 68462045535
|
| Hospital Charge Code |
25003186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem Medicaid |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.47
|
| Rate for Payer: First Health Commercial |
$9.69
|
| Rate for Payer: Humana Commercial |
$8.67
|
| Rate for Payer: Humana KY Medicaid |
$3.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.98
|
| Rate for Payer: Ohio Health Group HMO |
$7.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.79
|
| Rate for Payer: United Healthcare All Payer |
$8.98
|
|
|
LOPROX EQ 0.77% GEL 30 GRAM
|
Facility
|
IP
|
$10.20
|
|
|
Service Code
|
NDC 68462045535
|
| Hospital Charge Code |
25003186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.47
|
| Rate for Payer: First Health Commercial |
$9.69
|
| Rate for Payer: Humana Commercial |
$8.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.98
|
| Rate for Payer: Ohio Health Group HMO |
$7.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.79
|
| Rate for Payer: United Healthcare All Payer |
$8.98
|
|
|
LORAZEPAM 1mg Tablet
|
Facility
|
IP
|
$60.08
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.68 |
| Rate for Payer: Aetna Commercial |
$46.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.86
|
| Rate for Payer: Cash Price |
$30.04
|
| Rate for Payer: Cigna Commercial |
$49.87
|
| Rate for Payer: First Health Commercial |
$57.08
|
| Rate for Payer: Humana Commercial |
$51.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.87
|
| Rate for Payer: Ohio Health Group HMO |
$45.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.62
|
| Rate for Payer: PHCS Commercial |
$57.68
|
| Rate for Payer: United Healthcare All Payer |
$52.87
|
|
|
LORAZEPAM 1mg Tablet
|
Facility
|
OP
|
$60.08
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.68 |
| Rate for Payer: Aetna Commercial |
$46.26
|
| Rate for Payer: Anthem Medicaid |
$20.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.86
|
| Rate for Payer: Cash Price |
$30.04
|
| Rate for Payer: Cigna Commercial |
$49.87
|
| Rate for Payer: First Health Commercial |
$57.08
|
| Rate for Payer: Humana Commercial |
$51.07
|
| Rate for Payer: Humana KY Medicaid |
$20.66
|
| Rate for Payer: Kentucky WC Medicaid |
$20.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.87
|
| Rate for Payer: Ohio Health Group HMO |
$45.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.62
|
| Rate for Payer: PHCS Commercial |
$57.68
|
| Rate for Payer: United Healthcare All Payer |
$52.87
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
IP
|
$74.29
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
63600195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$71.32 |
| Rate for Payer: Aetna Commercial |
$57.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.95
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna Commercial |
$61.66
|
| Rate for Payer: First Health Commercial |
$70.58
|
| Rate for Payer: Humana Commercial |
$63.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.38
|
| Rate for Payer: Ohio Health Group HMO |
$55.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.03
|
| Rate for Payer: PHCS Commercial |
$71.32
|
| Rate for Payer: United Healthcare All Payer |
$65.38
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
IP
|
$74.29
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
636T0195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$71.32 |
| Rate for Payer: Aetna Commercial |
$57.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.95
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna Commercial |
$61.66
|
| Rate for Payer: First Health Commercial |
$70.58
|
| Rate for Payer: Humana Commercial |
$63.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.38
|
| Rate for Payer: Ohio Health Group HMO |
$55.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.03
|
| Rate for Payer: PHCS Commercial |
$71.32
|
| Rate for Payer: United Healthcare All Payer |
$65.38
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
OP
|
$74.29
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
63600195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$71.32 |
| Rate for Payer: Aetna Commercial |
$57.20
|
| Rate for Payer: Anthem Medicaid |
$25.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.95
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna Commercial |
$61.66
|
| Rate for Payer: First Health Commercial |
$70.58
|
| Rate for Payer: Humana Commercial |
$63.15
|
| Rate for Payer: Humana KY Medicaid |
$25.55
|
| Rate for Payer: Kentucky WC Medicaid |
$25.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.38
|
| Rate for Payer: Ohio Health Group HMO |
$55.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.03
|
| Rate for Payer: PHCS Commercial |
$71.32
|
| Rate for Payer: United Healthcare All Payer |
$65.38
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
OP
|
$74.29
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
636T0195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$71.32 |
| Rate for Payer: Aetna Commercial |
$57.20
|
| Rate for Payer: Anthem Medicaid |
$25.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.95
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna Commercial |
$61.66
|
| Rate for Payer: First Health Commercial |
$70.58
|
| Rate for Payer: Humana Commercial |
$63.15
|
| Rate for Payer: Humana KY Medicaid |
$25.55
|
| Rate for Payer: Kentucky WC Medicaid |
$25.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.38
|
| Rate for Payer: Ohio Health Group HMO |
$55.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.03
|
| Rate for Payer: PHCS Commercial |
$71.32
|
| Rate for Payer: United Healthcare All Payer |
$65.38
|
|
|
LORAZEPAM 2MG SDV
|
Professional
|
Both
|
$74.29
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
63600195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$1.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.29
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.01
|
| Rate for Payer: Multiplan PHCS |
$44.57
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.00
|
| Rate for Payer: UHCCP Medicaid |
$26.00
|
|
|
LOTEMAX(LOTEPREDNOLE).5%OPT5ML
|
Facility
|
OP
|
$6.32
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Anthem Medicaid |
$2.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.93
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna Commercial |
$5.25
|
| Rate for Payer: First Health Commercial |
$6.00
|
| Rate for Payer: Humana Commercial |
$5.37
|
| Rate for Payer: Humana KY Medicaid |
$2.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.56
|
| Rate for Payer: Ohio Health Group HMO |
$4.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.96
|
| Rate for Payer: PHCS Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Payer |
$5.56
|
| Rate for Payer: Aetna Commercial |
$4.87
|
|
|
LOTEMAX(LOTEPREDNOLE).5%OPT5ML
|
Facility
|
IP
|
$6.32
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna Commercial |
$4.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.93
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna Commercial |
$5.25
|
| Rate for Payer: First Health Commercial |
$6.00
|
| Rate for Payer: Humana Commercial |
$5.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.56
|
| Rate for Payer: Ohio Health Group HMO |
$4.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.96
|
| Rate for Payer: PHCS Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Payer |
$5.56
|
|
|
LOTENSIN (BENAZEPRIL 10MG/1TAB
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 65162075210
|
| Hospital Charge Code |
25000911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
LOTENSIN (BENAZEPRIL 10MG/1TAB
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 65162075210
|
| Hospital Charge Code |
25000911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
LOTRIMIN(CLOTRIMAZOLE) 1% 15GM
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 45802043401
|
| Hospital Charge Code |
25000913
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna Commercial |
$0.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.18
|
| Rate for Payer: First Health Commercial |
$0.21
|
| Rate for Payer: Humana Commercial |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.19
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Payer |
$0.19
|
|
|
LOTRIMIN(CLOTRIMAZOLE) 1% 15GM
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 45802043401
|
| Hospital Charge Code |
25000913
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna Commercial |
$0.17
|
| Rate for Payer: Anthem Medicaid |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.18
|
| Rate for Payer: First Health Commercial |
$0.21
|
| Rate for Payer: Humana Commercial |
$0.19
|
| Rate for Payer: Humana KY Medicaid |
$0.08
|
| Rate for Payer: Kentucky WC Medicaid |
$0.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.19
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Payer |
$0.19
|
|
|
LOTRIMIN(CLOTRIMAZOLE)CR1%30GM
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 24385020503
|
| Hospital Charge Code |
25000914
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna Commercial |
$0.06
|
| Rate for Payer: Anthem Medicaid |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.07
|
| Rate for Payer: First Health Commercial |
$0.08
|
| Rate for Payer: Humana Commercial |
$0.07
|
| Rate for Payer: Humana KY Medicaid |
$0.03
|
| Rate for Payer: Kentucky WC Medicaid |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.07
|
| Rate for Payer: Ohio Health Group HMO |
$0.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Payer |
$0.07
|
|
