|
LOTRIMIN(CLOTRIMAZOLE)CR1%30GM
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
LOTRISONE(CLOTRIM/BETAMET 15GM
|
Facility
|
IP
|
$6.12
|
|
|
Service Code
|
NDC 168025815
|
| Hospital Charge Code |
25000915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna Commercial |
$4.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.77
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna Commercial |
$5.08
|
| Rate for Payer: First Health Commercial |
$5.81
|
| Rate for Payer: Humana Commercial |
$5.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.39
|
| Rate for Payer: Ohio Health Group HMO |
$4.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.22
|
| 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 |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
LOTRISONE(CLOTRIM/BETAMET 15GM
|
Facility
|
OP
|
$6.12
|
|
|
Service Code
|
NDC 168025815
|
| Hospital Charge Code |
25000915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$5.88 |
| Rate for Payer: Aetna Commercial |
$4.71
|
| Rate for Payer: Anthem Medicaid |
$2.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.77
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna Commercial |
$5.08
|
| Rate for Payer: First Health Commercial |
$5.81
|
| Rate for Payer: Humana Commercial |
$5.20
|
| Rate for Payer: Humana KY Medicaid |
$2.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.39
|
| Rate for Payer: Ohio Health Group HMO |
$4.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.22
|
| 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 |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
LOTRISONE(CLOTRIM/BETAMET 45GM
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 168025846
|
| Hospital Charge Code |
25000916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Aetna Commercial |
$3.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: First Health Commercial |
$3.95
|
| Rate for Payer: Humana Commercial |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.66
|
| Rate for Payer: Ohio Health Group HMO |
$3.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.29
|
| Rate for Payer: PHCS Commercial |
$3.99
|
| Rate for Payer: United Healthcare All Payer |
$3.66
|
|
|
LOTRISONE(CLOTRIM/BETAMET 45GM
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 168025846
|
| Hospital Charge Code |
25000916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Aetna Commercial |
$3.20
|
| Rate for Payer: Anthem Medicaid |
$1.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: First Health Commercial |
$3.95
|
| Rate for Payer: Humana Commercial |
$3.54
|
| Rate for Payer: Humana KY Medicaid |
$1.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.66
|
| Rate for Payer: Ohio Health Group HMO |
$3.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.29
|
| Rate for Payer: PHCS Commercial |
$3.99
|
| Rate for Payer: United Healthcare All Payer |
$3.66
|
|
|
LOVENOX 10MG [100MG SYRINGE]
|
Facility
|
OP
|
$129.35
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$124.18 |
| Rate for Payer: Aetna Commercial |
$99.60
|
| Rate for Payer: Anthem Medicaid |
$44.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.89
|
| Rate for Payer: Cash Price |
$64.67
|
| Rate for Payer: Cigna Commercial |
$107.36
|
| Rate for Payer: First Health Commercial |
$122.88
|
| Rate for Payer: Humana Commercial |
$109.95
|
| Rate for Payer: Humana KY Medicaid |
$44.48
|
| Rate for Payer: Kentucky WC Medicaid |
$44.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.83
|
| Rate for Payer: Ohio Health Group HMO |
$97.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.10
|
| Rate for Payer: PHCS Commercial |
$124.18
|
| Rate for Payer: United Healthcare All Payer |
$113.83
|
|
|
LOVENOX 10MG [100MG SYRINGE]
|
Facility
|
IP
|
$129.35
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$124.18 |
| Rate for Payer: Aetna Commercial |
$99.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.89
|
| Rate for Payer: Cash Price |
$64.67
|
| Rate for Payer: Cigna Commercial |
$107.36
|
| Rate for Payer: First Health Commercial |
$122.88
|
| Rate for Payer: Humana Commercial |
$109.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.83
|
| Rate for Payer: Ohio Health Group HMO |
$97.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.10
|
| Rate for Payer: PHCS Commercial |
$124.18
|
| Rate for Payer: United Healthcare All Payer |
$113.83
|
|
|
LOVENOX 10MG (120MG SYRINGE)
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.75
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
LOVENOX 10MG (120MG SYRINGE)
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem Medicaid |
$42.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Humana KY Medicaid |
$42.99
|
| Rate for Payer: Kentucky WC Medicaid |
$43.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.75
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
LOVENOX 10MG (150MG SYRINGE)
|
Facility
|
IP
|
$187.86
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$180.35 |
| Rate for Payer: Aetna Commercial |
$144.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.53
|
| Rate for Payer: Cash Price |
$93.93
|
| Rate for Payer: Cigna Commercial |
$155.92
|
| Rate for Payer: First Health Commercial |
$178.47
|
| Rate for Payer: Humana Commercial |
$159.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$165.32
|
| Rate for Payer: Ohio Health Group HMO |
$140.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.24
|
| Rate for Payer: PHCS Commercial |
$180.35
|
| Rate for Payer: United Healthcare All Payer |
$165.32
|
|
|
LOVENOX 10MG (150MG SYRINGE)
|
Facility
|
OP
|
$187.86
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$180.35 |
| Rate for Payer: Kentucky WC Medicaid |
$65.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$165.32
|
| Rate for Payer: Ohio Health Group HMO |
$140.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.24
|
| Rate for Payer: PHCS Commercial |
$180.35
|
| Rate for Payer: United Healthcare All Payer |
$165.32
|
| Rate for Payer: Aetna Commercial |
$144.65
|
| Rate for Payer: Anthem Medicaid |
$64.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.53
|
| Rate for Payer: Cash Price |
$93.93
|
| Rate for Payer: Cigna Commercial |
$155.92
|
| Rate for Payer: First Health Commercial |
$178.47
|
| Rate for Payer: Humana Commercial |
$159.68
|
| Rate for Payer: Humana KY Medicaid |
$64.61
|
|
|
LOVENOX 10MG (30MG SYRINGE)
|
Facility
|
OP
|
$112.97
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.45 |
| Rate for Payer: Aetna Commercial |
$86.99
|
| Rate for Payer: Anthem Medicaid |
$38.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.12
|
| Rate for Payer: Cash Price |
$56.48
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: First Health Commercial |
$107.32
|
| Rate for Payer: Humana Commercial |
$96.02
|
| Rate for Payer: Humana KY Medicaid |
$38.85
|
| Rate for Payer: Kentucky WC Medicaid |
$39.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.41
|
| Rate for Payer: Ohio Health Group HMO |
$84.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.02
|
| Rate for Payer: PHCS Commercial |
$108.45
|
| Rate for Payer: United Healthcare All Payer |
$99.41
|
|
|
LOVENOX 10MG (30MG SYRINGE)
|
Facility
|
IP
|
$112.97
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.45 |
| Rate for Payer: Aetna Commercial |
$86.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.12
|
| Rate for Payer: Cash Price |
$56.48
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: First Health Commercial |
$107.32
|
| Rate for Payer: Humana Commercial |
$96.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.41
|
| Rate for Payer: Ohio Health Group HMO |
$84.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.02
|
| Rate for Payer: PHCS Commercial |
$108.45
|
| Rate for Payer: United Healthcare All Payer |
$99.41
|
|
|
LOVENOX 10MG (40MG SYRINGE)
|
Facility
|
IP
|
$114.94
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.94 |
| Max. Negotiated Rate |
$110.34 |
| Rate for Payer: Aetna Commercial |
$88.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.65
|
| Rate for Payer: Cash Price |
$57.47
|
| Rate for Payer: Cigna Commercial |
$95.40
|
| Rate for Payer: First Health Commercial |
$109.19
|
| Rate for Payer: Humana Commercial |
$97.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.15
|
| Rate for Payer: Ohio Health Group HMO |
$86.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.63
|
| Rate for Payer: PHCS Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Payer |
$101.15
|
|
|
LOVENOX 10MG (40MG SYRINGE)
|
Facility
|
OP
|
$114.94
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.94 |
| Max. Negotiated Rate |
$110.34 |
| Rate for Payer: Aetna Commercial |
$88.50
|
| Rate for Payer: Anthem Medicaid |
$39.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.65
|
| Rate for Payer: Cash Price |
$57.47
|
| Rate for Payer: Cigna Commercial |
$95.40
|
| Rate for Payer: First Health Commercial |
$109.19
|
| Rate for Payer: Humana Commercial |
$97.70
|
| Rate for Payer: Humana KY Medicaid |
$39.53
|
| Rate for Payer: Kentucky WC Medicaid |
$39.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.15
|
| Rate for Payer: Ohio Health Group HMO |
$86.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.63
|
| Rate for Payer: PHCS Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Payer |
$101.15
|
|
|
LOVENOX 10MG (60MG SYRINGE)
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
LOVENOX 10MG (60MG SYRINGE)
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
LOVENOX 10MG [80MG SYRINGE]
|
Facility
|
IP
|
$114.40
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$109.82 |
| Rate for Payer: Aetna Commercial |
$88.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.23
|
| Rate for Payer: Cash Price |
$57.20
|
| Rate for Payer: Cigna Commercial |
$94.95
|
| Rate for Payer: First Health Commercial |
$108.68
|
| Rate for Payer: Humana Commercial |
$97.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.67
|
| Rate for Payer: Ohio Health Group HMO |
$85.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.46
|
| Rate for Payer: PHCS Commercial |
$109.82
|
| Rate for Payer: United Healthcare All Payer |
$100.67
|
|
|
LOVENOX 10MG [80MG SYRINGE]
|
Facility
|
OP
|
$114.40
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$109.82 |
| Rate for Payer: Aetna Commercial |
$88.09
|
| Rate for Payer: Anthem Medicaid |
$39.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.23
|
| Rate for Payer: Cash Price |
$57.20
|
| Rate for Payer: Cigna Commercial |
$94.95
|
| Rate for Payer: First Health Commercial |
$108.68
|
| Rate for Payer: Humana Commercial |
$97.24
|
| Rate for Payer: Humana KY Medicaid |
$39.34
|
| Rate for Payer: Kentucky WC Medicaid |
$39.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.67
|
| Rate for Payer: Ohio Health Group HMO |
$85.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.46
|
| Rate for Payer: PHCS Commercial |
$109.82
|
| Rate for Payer: United Healthcare All Payer |
$100.67
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$28,095.56
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$19,064.85 |
| Max. Negotiated Rate |
$28,095.56 |
| Rate for Payer: Anthem Medicaid |
$19,064.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20,068.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28,095.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$27,092.15
|
| Rate for Payer: Humana KY Medicaid |
$19,064.85
|
| Rate for Payer: Humana Medicare Advantage |
$20,068.26
|
| Rate for Payer: Kentucky WC Medicaid |
$19,255.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,081.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,446.14
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$40,500.36
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$27,482.39 |
| Max. Negotiated Rate |
$40,500.36 |
| Rate for Payer: Anthem Medicaid |
$27,482.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28,928.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$40,500.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$39,053.92
|
| Rate for Payer: Humana KY Medicaid |
$27,482.39
|
| Rate for Payer: Humana Medicare Advantage |
$28,928.83
|
| Rate for Payer: Kentucky WC Medicaid |
$27,757.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34,714.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,032.04
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$21,866.31
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$14,837.85 |
| Max. Negotiated Rate |
$21,866.31 |
| Rate for Payer: Anthem Medicaid |
$14,837.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,618.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,866.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,085.37
|
| Rate for Payer: Humana KY Medicaid |
$14,837.85
|
| Rate for Payer: Humana Medicare Advantage |
$15,618.79
|
| Rate for Payer: Kentucky WC Medicaid |
$14,986.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,742.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,134.61
|
|
|
LOWER EXTR. RT2V TIBIA/FIBULA
|
Facility
|
OP
|
$372.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
32000104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$48.36 |
| Max. Negotiated Rate |
$357.12 |
| Rate for Payer: Aetna Commercial |
$286.44
|
| Rate for Payer: Anthem Medicaid |
$127.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$308.76
|
| Rate for Payer: First Health Commercial |
$353.40
|
| Rate for Payer: Humana Commercial |
$316.20
|
| Rate for Payer: Humana KY Medicaid |
$127.93
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$129.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$274.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$327.36
|
| Rate for Payer: Ohio Health Group HMO |
$279.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.32
|
| Rate for Payer: PHCS Commercial |
$357.12
|
| Rate for Payer: United Healthcare All Payer |
$327.36
|
|
|
LOWER EXTR. RT2V TIBIA/FIBULA
|
Facility
|
IP
|
$372.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
32000104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$48.36 |
| Max. Negotiated Rate |
$357.12 |
| Rate for Payer: Aetna Commercial |
$286.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.16
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$308.76
|
| Rate for Payer: First Health Commercial |
$353.40
|
| Rate for Payer: Humana Commercial |
$316.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$274.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$327.36
|
| Rate for Payer: Ohio Health Group HMO |
$279.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.32
|
| Rate for Payer: PHCS Commercial |
$357.12
|
| Rate for Payer: United Healthcare All Payer |
$327.36
|
|
|
LOWER EXTR. RT2V TIBIA/FIBULA
|
Professional
|
Both
|
$372.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
32000104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Anthem Medicaid |
$21.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$372.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$41.98
|
| Rate for Payer: Healthspan PPO |
$38.28
|
| Rate for Payer: Humana Medicaid |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.68
|
| Rate for Payer: Molina Healthcare Passport |
$21.25
|
| Rate for Payer: Multiplan PHCS |
$223.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$260.40
|
| Rate for Payer: UHCCP Medicaid |
$130.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.46
|
|
