|
XYLOCAINE 1%+ EPI 1:100K(10ML)
|
Facility
|
OP
|
$79.47
|
|
|
Service Code
|
NDC 63323048201
|
| Hospital Charge Code |
25003619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$76.29 |
| Rate for Payer: Aetna Commercial |
$61.19
|
| Rate for Payer: Anthem Medicaid |
$27.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Cash Price |
$39.74
|
| Rate for Payer: Cigna Commercial |
$65.96
|
| Rate for Payer: First Health Commercial |
$75.50
|
| Rate for Payer: Humana Commercial |
$67.55
|
| Rate for Payer: Humana KY Medicaid |
$27.33
|
| Rate for Payer: Kentucky WC Medicaid |
$27.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.93
|
| Rate for Payer: Ohio Health Group HMO |
$59.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.64
|
| Rate for Payer: PHCS Commercial |
$76.29
|
| Rate for Payer: United Healthcare All Payer |
$69.93
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
IP
|
$78.38
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.30
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
OP
|
$78.38
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem Medicaid |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Humana KY Medicaid |
$26.95
|
| Rate for Payer: Kentucky WC Medicaid |
$27.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.30
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
OP
|
$75.38
|
|
| Hospital Charge Code |
636T0106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$72.36 |
| Rate for Payer: Aetna Commercial |
$58.04
|
| Rate for Payer: Anthem Medicaid |
$25.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.80
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna Commercial |
$62.57
|
| Rate for Payer: First Health Commercial |
$71.61
|
| Rate for Payer: Humana Commercial |
$64.07
|
| Rate for Payer: Humana KY Medicaid |
$25.92
|
| Rate for Payer: Kentucky WC Medicaid |
$26.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.33
|
| Rate for Payer: Ohio Health Group HMO |
$56.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.37
|
| Rate for Payer: PHCS Commercial |
$72.36
|
| Rate for Payer: United Healthcare All Payer |
$66.33
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
OP
|
$75.38
|
|
| Hospital Charge Code |
63600106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$72.36 |
| Rate for Payer: Aetna Commercial |
$58.04
|
| Rate for Payer: Anthem Medicaid |
$25.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.80
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna Commercial |
$62.57
|
| Rate for Payer: First Health Commercial |
$71.61
|
| Rate for Payer: Humana Commercial |
$64.07
|
| Rate for Payer: Humana KY Medicaid |
$25.92
|
| Rate for Payer: Kentucky WC Medicaid |
$26.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.33
|
| Rate for Payer: Ohio Health Group HMO |
$56.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.37
|
| Rate for Payer: PHCS Commercial |
$72.36
|
| Rate for Payer: United Healthcare All Payer |
$66.33
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
IP
|
$75.38
|
|
| Hospital Charge Code |
63600106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$72.36 |
| Rate for Payer: Aetna Commercial |
$58.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.80
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna Commercial |
$62.57
|
| Rate for Payer: First Health Commercial |
$71.61
|
| Rate for Payer: Humana Commercial |
$64.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.33
|
| Rate for Payer: Ohio Health Group HMO |
$56.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.37
|
| Rate for Payer: PHCS Commercial |
$72.36
|
| Rate for Payer: United Healthcare All Payer |
$66.33
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Professional
|
Both
|
$75.38
|
|
| Hospital Charge Code |
63600106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.38 |
| Max. Negotiated Rate |
$75.38 |
| Rate for Payer: Buckeye Medicare Advantage |
$75.38
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Multiplan PHCS |
$45.23
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.77
|
| Rate for Payer: UHCCP Medicaid |
$26.38
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
IP
|
$75.38
|
|
| Hospital Charge Code |
636T0106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$72.36 |
| Rate for Payer: Aetna Commercial |
$58.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.80
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna Commercial |
$62.57
|
| Rate for Payer: First Health Commercial |
$71.61
|
| Rate for Payer: Humana Commercial |
$64.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.33
|
| Rate for Payer: Ohio Health Group HMO |
$56.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.37
|
| Rate for Payer: PHCS Commercial |
$72.36
|
| Rate for Payer: United Healthcare All Payer |
$66.33
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Humana KY Medicaid |
$27.64
|
| Rate for Payer: Kentucky WC Medicaid |
$27.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.91
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem Medicaid |
$27.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.91
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Professional
|
Both
|
$77.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$77.37 |
| Rate for Payer: Buckeye Medicare Advantage |
$77.37
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$46.42
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.16
|
| Rate for Payer: UHCCP Medicaid |
$27.08
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
IP
|
$77.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.28 |
| Rate for Payer: Aetna Commercial |
$59.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.35
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cigna Commercial |
$64.22
|
| Rate for Payer: First Health Commercial |
$73.50
|
| Rate for Payer: Humana Commercial |
$65.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.09
|
| Rate for Payer: Ohio Health Group HMO |
$58.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.98
|
| Rate for Payer: PHCS Commercial |
$74.28
|
| Rate for Payer: United Healthcare All Payer |
$68.09
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
IP
|
$77.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.28 |
| Rate for Payer: Aetna Commercial |
$59.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.35
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cigna Commercial |
$64.22
|
| Rate for Payer: First Health Commercial |
$73.50
|
| Rate for Payer: Humana Commercial |
$65.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.09
|
| Rate for Payer: Ohio Health Group HMO |
$58.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.98
|
| Rate for Payer: PHCS Commercial |
$74.28
|
| Rate for Payer: United Healthcare All Payer |
$68.09
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
OP
|
$77.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.28 |
| Rate for Payer: Aetna Commercial |
$59.57
|
| Rate for Payer: Anthem Medicaid |
$26.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.35
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cigna Commercial |
$64.22
|
| Rate for Payer: First Health Commercial |
$73.50
|
| Rate for Payer: Humana Commercial |
$65.76
|
| Rate for Payer: Humana KY Medicaid |
$26.61
|
| Rate for Payer: Kentucky WC Medicaid |
$26.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.09
|
| Rate for Payer: Ohio Health Group HMO |
$58.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.98
|
| Rate for Payer: PHCS Commercial |
$74.28
|
| Rate for Payer: United Healthcare All Payer |
$68.09
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
OP
|
$77.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.28 |
| Rate for Payer: Aetna Commercial |
$59.57
|
| Rate for Payer: Anthem Medicaid |
$26.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.35
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cigna Commercial |
$64.22
|
| Rate for Payer: First Health Commercial |
$73.50
|
| Rate for Payer: Humana Commercial |
$65.76
|
| Rate for Payer: Humana KY Medicaid |
$26.61
|
| Rate for Payer: Kentucky WC Medicaid |
$26.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.09
|
| Rate for Payer: Ohio Health Group HMO |
$58.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.98
|
| Rate for Payer: PHCS Commercial |
$74.28
|
| Rate for Payer: United Healthcare All Payer |
$68.09
|
|
|
XYLOCAINE (LIDO) 0.5%/50 ML
|
Facility
|
OP
|
$80.74
|
|
|
Service Code
|
NDC 409427501
|
| Hospital Charge Code |
25003613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$77.51 |
| Rate for Payer: Aetna Commercial |
$62.17
|
| Rate for Payer: Anthem Medicaid |
$27.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.98
|
| Rate for Payer: Cash Price |
$40.37
|
| Rate for Payer: Cigna Commercial |
$67.01
|
| Rate for Payer: First Health Commercial |
$76.70
|
| Rate for Payer: Humana Commercial |
$68.63
|
| Rate for Payer: Humana KY Medicaid |
$27.77
|
| Rate for Payer: Kentucky WC Medicaid |
$28.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.05
|
| Rate for Payer: Ohio Health Group HMO |
$60.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.03
|
| Rate for Payer: PHCS Commercial |
$77.51
|
| Rate for Payer: United Healthcare All Payer |
$71.05
|
|
|
XYLOCAINE (LIDO) 0.5%/50 ML
|
Facility
|
IP
|
$80.74
|
|
|
Service Code
|
NDC 409427501
|
| Hospital Charge Code |
25003613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$77.51 |
| Rate for Payer: Aetna Commercial |
$62.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.98
|
| Rate for Payer: Cash Price |
$40.37
|
| Rate for Payer: Cigna Commercial |
$67.01
|
| Rate for Payer: First Health Commercial |
$76.70
|
| Rate for Payer: Humana Commercial |
$68.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.05
|
| Rate for Payer: Ohio Health Group HMO |
$60.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.03
|
| Rate for Payer: PHCS Commercial |
$77.51
|
| Rate for Payer: United Healthcare All Payer |
$71.05
|
|
|
XYLOCAINE(LIDO)[10MG]100MG/5ML
|
Facility
|
IP
|
$7.67
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
63600041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.98
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna Commercial |
$6.37
|
| Rate for Payer: First Health Commercial |
$7.29
|
| Rate for Payer: Humana Commercial |
$6.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6.75
|
| Rate for Payer: Ohio Health Group HMO |
$5.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.38
|
| Rate for Payer: PHCS Commercial |
$7.36
|
| Rate for Payer: United Healthcare All Payer |
$6.75
|
|
|
XYLOCAINE(LIDO)[10MG]100MG/5ML
|
Facility
|
IP
|
$7.67
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
636T0041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.98
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna Commercial |
$6.37
|
| Rate for Payer: First Health Commercial |
$7.29
|
| Rate for Payer: Humana Commercial |
$6.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6.75
|
| Rate for Payer: Ohio Health Group HMO |
$5.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.38
|
| Rate for Payer: PHCS Commercial |
$7.36
|
| Rate for Payer: United Healthcare All Payer |
$6.75
|
|
|
XYLOCAINE(LIDO)[10MG]100MG/5ML
|
Facility
|
OP
|
$7.67
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
636T0041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: Anthem Medicaid |
$2.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.98
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna Commercial |
$6.37
|
| Rate for Payer: First Health Commercial |
$7.29
|
| Rate for Payer: Humana Commercial |
$6.52
|
| Rate for Payer: Humana KY Medicaid |
$2.64
|
| Rate for Payer: Kentucky WC Medicaid |
$2.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6.75
|
| Rate for Payer: Ohio Health Group HMO |
$5.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.38
|
| Rate for Payer: PHCS Commercial |
$7.36
|
| Rate for Payer: United Healthcare All Payer |
$6.75
|
|
|
XYLOCAINE(LIDO)[10MG]100MG/5ML
|
Professional
|
Both
|
$7.67
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
63600041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$7.67 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$7.67
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Healthspan PPO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$0.04
|
| Rate for Payer: Multiplan PHCS |
$4.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.37
|
| Rate for Payer: UHCCP Medicaid |
$2.68
|
|
|
XYLOCAINE(LIDO)[10MG]100MG/5ML
|
Facility
|
OP
|
$7.67
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
63600041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: Anthem Medicaid |
$2.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.98
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna Commercial |
$6.37
|
| Rate for Payer: First Health Commercial |
$7.29
|
| Rate for Payer: Humana Commercial |
$6.52
|
| Rate for Payer: Humana KY Medicaid |
$2.64
|
| Rate for Payer: Kentucky WC Medicaid |
$2.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6.75
|
| Rate for Payer: Ohio Health Group HMO |
$5.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.38
|
| Rate for Payer: PHCS Commercial |
$7.36
|
| Rate for Payer: United Healthcare All Payer |
$6.75
|
|
|
XYLOCAINE(LIDO)[1MG]100MG/5ML
|
Facility
|
OP
|
$115.15
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25002215
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.97 |
| Max. Negotiated Rate |
$110.54 |
| Rate for Payer: Aetna Commercial |
$88.67
|
| Rate for Payer: Anthem Medicaid |
$39.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.82
|
| Rate for Payer: Cash Price |
$57.58
|
| Rate for Payer: Cigna Commercial |
$95.57
|
| Rate for Payer: First Health Commercial |
$109.39
|
| Rate for Payer: Humana Commercial |
$97.88
|
| Rate for Payer: Humana KY Medicaid |
$39.60
|
| Rate for Payer: Kentucky WC Medicaid |
$40.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.33
|
| Rate for Payer: Ohio Health Group HMO |
$86.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.70
|
| Rate for Payer: PHCS Commercial |
$110.54
|
| Rate for Payer: United Healthcare All Payer |
$101.33
|
|
|
XYLOCAINE(LIDO)[1MG]100MG/5ML
|
Facility
|
IP
|
$115.15
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25002215
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.97 |
| Max. Negotiated Rate |
$110.54 |
| Rate for Payer: Aetna Commercial |
$88.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.82
|
| Rate for Payer: Cash Price |
$57.58
|
| Rate for Payer: Cigna Commercial |
$95.57
|
| Rate for Payer: First Health Commercial |
$109.39
|
| Rate for Payer: Humana Commercial |
$97.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.33
|
| Rate for Payer: Ohio Health Group HMO |
$86.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.70
|
| Rate for Payer: PHCS Commercial |
$110.54
|
| Rate for Payer: United Healthcare All Payer |
$101.33
|
|
|
XYLOCAINE (LIDOCAI 2000MG/50ML
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 54350547
|
| Hospital Charge Code |
25003612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna Commercial |
$2.94
|
| Rate for Payer: Anthem Medicaid |
$1.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.98
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna Commercial |
$3.17
|
| Rate for Payer: First Health Commercial |
$3.63
|
| Rate for Payer: Humana Commercial |
$3.25
|
| Rate for Payer: Humana KY Medicaid |
$1.31
|
| Rate for Payer: Kentucky WC Medicaid |
$1.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.36
|
| Rate for Payer: Ohio Health Group HMO |
$2.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.18
|
| Rate for Payer: PHCS Commercial |
$3.67
|
| Rate for Payer: United Healthcare All Payer |
$3.36
|
|
