|
LOTRISONE(CLOTRIM/BETAMET 45GM
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 168025846
|
| Hospital Charge Code |
25000916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| 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 |
$3.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$3.99
|
| Rate for Payer: United Healthcare All Payer |
$3.66
|
|
|
LOTRISONE(CLOTRIM/BETAMET 45GM
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 168025846
|
| Hospital Charge Code |
25000916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| 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 |
$3.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$3.99
|
| Rate for Payer: United Healthcare All Payer |
$3.66
|
|
|
LOVENOX 10MG [100MG SYRINGE]
|
Facility
|
IP
|
$129.35
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.80 |
| 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 |
$103.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.25
|
| Rate for Payer: PHCS Commercial |
$124.18
|
| Rate for Payer: United Healthcare All Payer |
$113.83
|
|
|
LOVENOX 10MG [100MG SYRINGE]
|
Facility
|
OP
|
$129.35
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.80 |
| 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 |
$103.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.25
|
| Rate for Payer: PHCS Commercial |
$124.18
|
| Rate for Payer: United Healthcare All Payer |
$113.83
|
|
|
LOVENOX 10MG (120MG SYRINGE)
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.50 |
| 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 |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.25
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
LOVENOX 10MG (120MG SYRINGE)
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.50 |
| 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 |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.25
|
| 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 |
$56.36 |
| 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 |
$150.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.62
|
| 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 |
$56.36 |
| Max. Negotiated Rate |
$180.35 |
| 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
|
| 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 |
$150.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.62
|
| Rate for Payer: PHCS Commercial |
$180.35
|
| Rate for Payer: United Healthcare All Payer |
$165.32
|
|
|
LOVENOX 10MG (30MG SYRINGE)
|
Facility
|
OP
|
$112.97
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.89 |
| 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 |
$90.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.95
|
| 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 |
$33.89 |
| 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 |
$90.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.95
|
| Rate for Payer: PHCS Commercial |
$108.45
|
| Rate for Payer: United Healthcare All Payer |
$99.41
|
|
|
LOVENOX 10MG (40MG SYRINGE)
|
Facility
|
OP
|
$114.94
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.48 |
| 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 |
$91.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.31
|
| Rate for Payer: PHCS Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Payer |
$101.15
|
|
|
LOVENOX 10MG (40MG SYRINGE)
|
Facility
|
IP
|
$114.94
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.48 |
| 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 |
$91.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.31
|
| 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 |
$34.80 |
| 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 |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| 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 |
$34.80 |
| 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 |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
LOVENOX 10MG [80MG SYRINGE]
|
Facility
|
OP
|
$114.40
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.32 |
| 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 |
$91.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.94
|
| Rate for Payer: PHCS Commercial |
$109.82
|
| Rate for Payer: United Healthcare All Payer |
$100.67
|
|
|
LOVENOX 10MG [80MG SYRINGE]
|
Facility
|
IP
|
$114.40
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25002148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.32 |
| 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 |
$91.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.94
|
| Rate for Payer: PHCS Commercial |
$109.82
|
| Rate for Payer: United Healthcare All Payer |
$100.67
|
|
|
LOVENOX IV 10mg(300mgV)
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25004581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$180.48 |
| Rate for Payer: Aetna Commercial |
$144.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.64
|
| Rate for Payer: Cash Price |
$94.00
|
| Rate for Payer: Cigna Commercial |
$156.04
|
| Rate for Payer: First Health Commercial |
$178.60
|
| Rate for Payer: Humana Commercial |
$159.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$165.44
|
| Rate for Payer: Ohio Health Group HMO |
$141.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.72
|
| Rate for Payer: PHCS Commercial |
$180.48
|
| Rate for Payer: United Healthcare All Payer |
$165.44
|
|
|
LOVENOX IV 10mg(300mgV)
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
25004581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$180.48 |
| Rate for Payer: Aetna Commercial |
$144.76
|
| Rate for Payer: Anthem Medicaid |
$64.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.64
|
| Rate for Payer: Cash Price |
$94.00
|
| Rate for Payer: Cigna Commercial |
$156.04
|
| Rate for Payer: First Health Commercial |
$178.60
|
| Rate for Payer: Humana Commercial |
$159.80
|
| Rate for Payer: Humana KY Medicaid |
$64.65
|
| Rate for Payer: Kentucky WC Medicaid |
$65.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$165.44
|
| Rate for Payer: Ohio Health Group HMO |
$141.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.72
|
| Rate for Payer: PHCS Commercial |
$180.48
|
| Rate for Payer: United Healthcare All Payer |
$165.44
|
|
|
LOWER EXTR. RT2V TIBIA/FIBULA
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
32000104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$118.20 |
| Max. Negotiated Rate |
$378.24 |
| Rate for Payer: Aetna Commercial |
$303.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.32
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$327.02
|
| Rate for Payer: First Health Commercial |
$374.30
|
| Rate for Payer: Humana Commercial |
$334.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.72
|
| Rate for Payer: Ohio Health Group HMO |
$295.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.86
|
| Rate for Payer: PHCS Commercial |
$378.24
|
| Rate for Payer: United Healthcare All Payer |
$346.72
|
|
|
LOWER EXTR. RT2V TIBIA/FIBULA
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
32000104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$378.24 |
| Rate for Payer: Aetna Commercial |
$303.38
|
| Rate for Payer: Anthem Medicaid |
$135.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$327.02
|
| Rate for Payer: First Health Commercial |
$374.30
|
| Rate for Payer: Humana Commercial |
$334.90
|
| Rate for Payer: Humana KY Medicaid |
$135.50
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$136.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$138.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.72
|
| Rate for Payer: Ohio Health Group HMO |
$295.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.86
|
| Rate for Payer: PHCS Commercial |
$378.24
|
| Rate for Payer: United Healthcare All Payer |
$346.72
|
|
|
LOWER EXTR. RT2V TIBIA/FIBULA
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
32000104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$236.40 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Ambetter Exchange |
$28.53
|
| Rate for Payer: Anthem Medicaid |
$21.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.24
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cash Price |
$197.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$28.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.68
|
| Rate for Payer: Molina Healthcare Passport |
$21.25
|
| Rate for Payer: Multiplan PHCS |
$236.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.09
|
| Rate for Payer: UHCCP Medicaid |
$137.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.53
|
|
|
LOWER EXTR. RT2V TIBIA/FIBUL(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
320P0104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$41.98 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Ambetter Exchange |
$28.53
|
| Rate for Payer: Anthem Medicaid |
$21.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$28.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$28.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.24
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$28.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.68
|
| Rate for Payer: Molina Healthcare Passport |
$21.25
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.09
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$28.53
|
|
|
LOWER EXTR. RT2V TIBIA/FIBUL(T
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
320T0104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem Medicaid |
$121.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Humana KY Medicaid |
$121.74
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$122.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
|
LOWER EXTR. RT2V TIBIA/FIBUL(T
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
320T0104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.20 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
|
LOWER/UPPER RESP C/S W/ID
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
30001249
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$8.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.62
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Humana KY Medicaid |
$8.62
|
| Rate for Payer: Humana Medicare Advantage |
$8.62
|
| Rate for Payer: Kentucky WC Medicaid |
$8.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
