|
LOPRESSOR (METOPROLOL) 5MG/5ML
|
Facility
|
IP
|
$77.30
|
|
|
Service Code
|
NDC 409177805
|
| Hospital Charge Code |
25003691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$59.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.29
|
| Rate for Payer: Cash Price |
$38.65
|
| Rate for Payer: Cigna Commercial |
$64.16
|
| Rate for Payer: First Health Commercial |
$73.44
|
| Rate for Payer: Humana Commercial |
$65.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.02
|
| Rate for Payer: Ohio Health Group HMO |
$57.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.34
|
| Rate for Payer: PHCS Commercial |
$74.21
|
| Rate for Payer: United Healthcare All Payer |
$68.02
|
|
|
LOPRESSOR (METOPROLOL) 5MG/5ML
|
Facility
|
OP
|
$77.30
|
|
|
Service Code
|
NDC 409177805
|
| Hospital Charge Code |
25003691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$59.52
|
| Rate for Payer: Anthem Medicaid |
$26.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.29
|
| Rate for Payer: Cash Price |
$38.65
|
| Rate for Payer: Cigna Commercial |
$64.16
|
| Rate for Payer: First Health Commercial |
$73.44
|
| Rate for Payer: Humana Commercial |
$65.70
|
| Rate for Payer: Humana KY Medicaid |
$26.58
|
| Rate for Payer: Kentucky WC Medicaid |
$26.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.02
|
| Rate for Payer: Ohio Health Group HMO |
$57.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.34
|
| Rate for Payer: PHCS Commercial |
$74.21
|
| Rate for Payer: United Healthcare All Payer |
$68.02
|
|
|
LOPRESSOR(METOPROLOL) 5MG/5ML
|
Facility
|
OP
|
$77.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003185
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$59.52
|
| Rate for Payer: Anthem Medicaid |
$26.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.29
|
| Rate for Payer: Cash Price |
$38.65
|
| Rate for Payer: Cigna Commercial |
$64.16
|
| Rate for Payer: First Health Commercial |
$73.44
|
| Rate for Payer: Humana Commercial |
$65.70
|
| Rate for Payer: Humana KY Medicaid |
$26.58
|
| Rate for Payer: Kentucky WC Medicaid |
$26.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.02
|
| Rate for Payer: Ohio Health Group HMO |
$57.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.34
|
| Rate for Payer: PHCS Commercial |
$74.21
|
| Rate for Payer: United Healthcare All Payer |
$68.02
|
|
|
LOPRESSOR(METOPROLOL) 5MG/5ML
|
Facility
|
IP
|
$77.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003185
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$74.21 |
| Rate for Payer: Aetna Commercial |
$59.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.29
|
| Rate for Payer: Cash Price |
$38.65
|
| Rate for Payer: Cigna Commercial |
$64.16
|
| Rate for Payer: First Health Commercial |
$73.44
|
| Rate for Payer: Humana Commercial |
$65.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.02
|
| Rate for Payer: Ohio Health Group HMO |
$57.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.34
|
| Rate for Payer: PHCS Commercial |
$74.21
|
| Rate for Payer: United Healthcare All Payer |
$68.02
|
|
|
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 |
$1.84 |
| 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 |
$4.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.24
|
| 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 |
$1.84 |
| 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 |
$4.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.24
|
| 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 |
$3.06 |
| 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 |
$8.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.04
|
| 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 |
$3.06 |
| 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 |
$8.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.04
|
| Rate for Payer: PHCS Commercial |
$9.79
|
| Rate for Payer: United Healthcare All Payer |
$8.98
|
|
|
LORAZEPAM 1mg Tablet
|
Facility
|
OP
|
$60.08
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.02 |
| 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 |
$48.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.46
|
| Rate for Payer: PHCS Commercial |
$57.68
|
| Rate for Payer: United Healthcare All Payer |
$52.87
|
|
|
LORAZEPAM 1mg Tablet
|
Facility
|
IP
|
$60.08
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.02 |
| 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 |
$48.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.46
|
| Rate for Payer: PHCS Commercial |
$57.68
|
| Rate for Payer: United Healthcare All Payer |
$52.87
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
OP
|
$76.42
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
63600195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$73.36 |
| Rate for Payer: Aetna Commercial |
$58.84
|
| Rate for Payer: Anthem Medicaid |
$26.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.61
|
| Rate for Payer: Cash Price |
$38.21
|
| Rate for Payer: Cigna Commercial |
$63.43
|
| Rate for Payer: First Health Commercial |
$72.60
|
| Rate for Payer: Humana Commercial |
$64.96
|
| Rate for Payer: Humana KY Medicaid |
$26.28
|
| Rate for Payer: Kentucky WC Medicaid |
$26.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.25
|
| Rate for Payer: Ohio Health Group HMO |
$57.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.73
|
| Rate for Payer: PHCS Commercial |
$73.36
|
| Rate for Payer: United Healthcare All Payer |
$67.25
|
|
|
LORAZEPAM 2MG SDV
|
Professional
|
Both
|
$76.42
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
63600195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$45.85 |
| Rate for Payer: Aetna Commercial |
$1.07
|
| Rate for Payer: Ambetter Exchange |
$1.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$1.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.58
|
| Rate for Payer: Cash Price |
$38.21
|
| Rate for Payer: Cash Price |
$38.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Multiplan PHCS |
$45.85
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.72
|
| Rate for Payer: UHCCP Medicaid |
$26.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$1.32
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
OP
|
$76.42
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
636T0195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$73.36 |
| Rate for Payer: Aetna Commercial |
$58.84
|
| Rate for Payer: Anthem Medicaid |
$26.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.61
|
| Rate for Payer: Cash Price |
$38.21
|
| Rate for Payer: Cigna Commercial |
$63.43
|
| Rate for Payer: First Health Commercial |
$72.60
|
| Rate for Payer: Humana Commercial |
$64.96
|
| Rate for Payer: Humana KY Medicaid |
$26.28
|
| Rate for Payer: Kentucky WC Medicaid |
$26.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.25
|
| Rate for Payer: Ohio Health Group HMO |
$57.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.73
|
| Rate for Payer: PHCS Commercial |
$73.36
|
| Rate for Payer: United Healthcare All Payer |
$67.25
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
IP
|
$76.42
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
636T0195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$73.36 |
| Rate for Payer: Aetna Commercial |
$58.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.61
|
| Rate for Payer: Cash Price |
$38.21
|
| Rate for Payer: Cigna Commercial |
$63.43
|
| Rate for Payer: First Health Commercial |
$72.60
|
| Rate for Payer: Humana Commercial |
$64.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.25
|
| Rate for Payer: Ohio Health Group HMO |
$57.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.73
|
| Rate for Payer: PHCS Commercial |
$73.36
|
| Rate for Payer: United Healthcare All Payer |
$67.25
|
|
|
LORAZEPAM 2MG SDV
|
Facility
|
IP
|
$76.42
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
63600195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$73.36 |
| Rate for Payer: Aetna Commercial |
$58.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.61
|
| Rate for Payer: Cash Price |
$38.21
|
| Rate for Payer: Cigna Commercial |
$63.43
|
| Rate for Payer: First Health Commercial |
$72.60
|
| Rate for Payer: Humana Commercial |
$64.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.25
|
| Rate for Payer: Ohio Health Group HMO |
$57.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.73
|
| Rate for Payer: PHCS Commercial |
$73.36
|
| Rate for Payer: United Healthcare All Payer |
$67.25
|
|
|
LOTEMAX(LOTEPREDNOLE).5%OPT5ML
|
Facility
|
IP
|
$6.32
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| 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 |
$5.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.36
|
| Rate for Payer: PHCS Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Payer |
$5.56
|
|
|
LOTEMAX(LOTEPREDNOLE).5%OPT5ML
|
Facility
|
OP
|
$6.32
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna Commercial |
$4.87
|
| 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 |
$5.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.36
|
| 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 |
$1.29 |
| 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 |
$3.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.96
|
| 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 |
$1.29 |
| 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 |
$3.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.96
|
| 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 |
$0.07 |
| 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 |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| 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 |
$0.07 |
| 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 |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| 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 |
$0.02 |
| 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 |
$0.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Payer |
$0.07
|
|
|
LOTRIMIN(CLOTRIMAZOLE)CR1%30GM
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 24385020503
|
| Hospital Charge Code |
25000914
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| 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 |
$0.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Payer |
$0.07
|
|
|
LOTRISONE(CLOTRIM/BETAMET 15GM
|
Facility
|
OP
|
$6.12
|
|
|
Service Code
|
NDC 168025815
|
| Hospital Charge Code |
25000915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| 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 |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.22
|
| Rate for Payer: PHCS Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
|
LOTRISONE(CLOTRIM/BETAMET 15GM
|
Facility
|
IP
|
$6.12
|
|
|
Service Code
|
NDC 168025815
|
| Hospital Charge Code |
25000915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| 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 |
$4.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.22
|
| Rate for Payer: PHCS Commercial |
$5.88
|
| Rate for Payer: United Healthcare All Payer |
$5.39
|
|
