|
XYLOCAINE (LIDOCAI 2000MG/50ML
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
XYLOCAINE(LIDOCAINE 250MG/50ML
|
Facility
|
IP
|
$80.32
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.44 |
| Max. Negotiated Rate |
$77.11 |
| Rate for Payer: Aetna Commercial |
$61.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.65
|
| Rate for Payer: Cash Price |
$40.16
|
| Rate for Payer: Cigna Commercial |
$66.67
|
| Rate for Payer: First Health Commercial |
$76.30
|
| Rate for Payer: Humana Commercial |
$68.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.68
|
| Rate for Payer: Ohio Health Group HMO |
$60.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.90
|
| Rate for Payer: PHCS Commercial |
$77.11
|
| Rate for Payer: United Healthcare All Payer |
$70.68
|
|
|
XYLOCAINE(LIDOCAINE 250MG/50ML
|
Facility
|
OP
|
$80.32
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.44 |
| Max. Negotiated Rate |
$77.11 |
| Rate for Payer: Aetna Commercial |
$61.85
|
| Rate for Payer: Anthem Medicaid |
$27.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.65
|
| Rate for Payer: Cash Price |
$40.16
|
| Rate for Payer: Cigna Commercial |
$66.67
|
| Rate for Payer: First Health Commercial |
$76.30
|
| Rate for Payer: Humana Commercial |
$68.27
|
| Rate for Payer: Humana KY Medicaid |
$27.62
|
| Rate for Payer: Kentucky WC Medicaid |
$27.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.68
|
| Rate for Payer: Ohio Health Group HMO |
$60.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.90
|
| Rate for Payer: PHCS Commercial |
$77.11
|
| Rate for Payer: United Healthcare All Payer |
$70.68
|
|
|
XYLOCAINE (LIDOCAINE) 2%/50 ML
|
Facility
|
OP
|
$114.13
|
|
|
Service Code
|
NDC 63323048605
|
| Hospital Charge Code |
25003852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$109.56 |
| Rate for Payer: Aetna Commercial |
$87.88
|
| Rate for Payer: Anthem Medicaid |
$39.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.02
|
| Rate for Payer: Cash Price |
$57.06
|
| Rate for Payer: Cigna Commercial |
$94.73
|
| Rate for Payer: First Health Commercial |
$108.42
|
| Rate for Payer: Humana Commercial |
$97.01
|
| Rate for Payer: Humana KY Medicaid |
$39.25
|
| Rate for Payer: Kentucky WC Medicaid |
$39.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.43
|
| Rate for Payer: Ohio Health Group HMO |
$85.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.38
|
| Rate for Payer: PHCS Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Payer |
$100.43
|
|
|
XYLOCAINE (LIDOCAINE) 2%/50 ML
|
Facility
|
IP
|
$114.13
|
|
|
Service Code
|
NDC 63323048605
|
| Hospital Charge Code |
25003852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$109.56 |
| Rate for Payer: Aetna Commercial |
$87.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.02
|
| Rate for Payer: Cash Price |
$57.06
|
| Rate for Payer: Cigna Commercial |
$94.73
|
| Rate for Payer: First Health Commercial |
$108.42
|
| Rate for Payer: Humana Commercial |
$97.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.43
|
| Rate for Payer: Ohio Health Group HMO |
$85.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.38
|
| Rate for Payer: PHCS Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Payer |
$100.43
|
|
|
XYLOCAINE (LIDOCAINE) 5% 35GM
|
Facility
|
OP
|
$5.10
|
|
|
Service Code
|
NDC 68462041820
|
| Hospital Charge Code |
25003615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.98
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cigna Commercial |
$4.23
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.34
|
| Rate for Payer: Humana KY Medicaid |
$1.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.49
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.90
|
| Rate for Payer: United Healthcare All Payer |
$4.49
|
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
|
|
XYLOCAINE (LIDOCAINE) 5% 35GM
|
Facility
|
IP
|
$5.10
|
|
|
Service Code
|
NDC 68462041820
|
| Hospital Charge Code |
25003615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.98
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cigna Commercial |
$4.23
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.49
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.90
|
| Rate for Payer: United Healthcare All Payer |
$4.49
|
|
|
XYLOCAINE MPF 1%+EPINEP 1:200K
|
Facility
|
IP
|
$118.83
|
|
|
Service Code
|
NDC 63323048701
|
| Hospital Charge Code |
25003622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.45 |
| Max. Negotiated Rate |
$114.08 |
| Rate for Payer: Aetna Commercial |
$91.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.69
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cigna Commercial |
$98.63
|
| Rate for Payer: First Health Commercial |
$112.89
|
| Rate for Payer: Humana Commercial |
$101.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.57
|
| Rate for Payer: Ohio Health Group HMO |
$89.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.84
|
| Rate for Payer: PHCS Commercial |
$114.08
|
| Rate for Payer: United Healthcare All Payer |
$104.57
|
|
|
XYLOCAINE MPF 1%+EPINEP 1:200K
|
Facility
|
OP
|
$118.83
|
|
|
Service Code
|
NDC 63323048701
|
| Hospital Charge Code |
25003622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.45 |
| Max. Negotiated Rate |
$114.08 |
| Rate for Payer: Aetna Commercial |
$91.50
|
| Rate for Payer: Anthem Medicaid |
$40.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.69
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cigna Commercial |
$98.63
|
| Rate for Payer: First Health Commercial |
$112.89
|
| Rate for Payer: Humana Commercial |
$101.01
|
| Rate for Payer: Humana KY Medicaid |
$40.87
|
| Rate for Payer: Kentucky WC Medicaid |
$41.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.57
|
| Rate for Payer: Ohio Health Group HMO |
$89.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.84
|
| Rate for Payer: PHCS Commercial |
$114.08
|
| Rate for Payer: United Healthcare All Payer |
$104.57
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
IP
|
$108.03
|
|
| Hospital Charge Code |
63600123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$103.71 |
| Rate for Payer: Aetna Commercial |
$83.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.26
|
| Rate for Payer: Cash Price |
$54.02
|
| Rate for Payer: Cigna Commercial |
$89.66
|
| Rate for Payer: First Health Commercial |
$102.63
|
| Rate for Payer: Humana Commercial |
$91.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.07
|
| Rate for Payer: Ohio Health Group HMO |
$81.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.49
|
| Rate for Payer: PHCS Commercial |
$103.71
|
| Rate for Payer: United Healthcare All Payer |
$95.07
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
OP
|
$108.03
|
|
| Hospital Charge Code |
63600123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$103.71 |
| Rate for Payer: Aetna Commercial |
$83.18
|
| Rate for Payer: Anthem Medicaid |
$37.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.26
|
| Rate for Payer: Cash Price |
$54.02
|
| Rate for Payer: Cigna Commercial |
$89.66
|
| Rate for Payer: First Health Commercial |
$102.63
|
| Rate for Payer: Humana Commercial |
$91.83
|
| Rate for Payer: Humana KY Medicaid |
$37.15
|
| Rate for Payer: Kentucky WC Medicaid |
$37.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.07
|
| Rate for Payer: Ohio Health Group HMO |
$81.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.49
|
| Rate for Payer: PHCS Commercial |
$103.71
|
| Rate for Payer: United Healthcare All Payer |
$95.07
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
OP
|
$113.93
|
|
|
Service Code
|
NDC 409428212
|
| Hospital Charge Code |
25004045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$109.37 |
| Rate for Payer: Aetna Commercial |
$87.73
|
| Rate for Payer: Anthem Medicaid |
$39.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.87
|
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: First Health Commercial |
$108.23
|
| Rate for Payer: Humana Commercial |
$96.84
|
| Rate for Payer: Humana KY Medicaid |
$39.18
|
| Rate for Payer: Kentucky WC Medicaid |
$39.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.26
|
| Rate for Payer: Ohio Health Group HMO |
$85.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.32
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
OP
|
$108.03
|
|
| Hospital Charge Code |
636T0123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$103.71 |
| Rate for Payer: Aetna Commercial |
$83.18
|
| Rate for Payer: Anthem Medicaid |
$37.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.26
|
| Rate for Payer: Cash Price |
$54.02
|
| Rate for Payer: Cigna Commercial |
$89.66
|
| Rate for Payer: First Health Commercial |
$102.63
|
| Rate for Payer: Humana Commercial |
$91.83
|
| Rate for Payer: Humana KY Medicaid |
$37.15
|
| Rate for Payer: Kentucky WC Medicaid |
$37.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.07
|
| Rate for Payer: Ohio Health Group HMO |
$81.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.49
|
| Rate for Payer: PHCS Commercial |
$103.71
|
| Rate for Payer: United Healthcare All Payer |
$95.07
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Professional
|
Both
|
$108.03
|
|
| Hospital Charge Code |
63600123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.81 |
| Max. Negotiated Rate |
$108.03 |
| Rate for Payer: Buckeye Medicare Advantage |
$108.03
|
| Rate for Payer: Cash Price |
$54.02
|
| Rate for Payer: Multiplan PHCS |
$64.82
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$75.62
|
| Rate for Payer: UHCCP Medicaid |
$37.81
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
IP
|
$113.93
|
|
|
Service Code
|
NDC 409428212
|
| Hospital Charge Code |
25004045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$109.37 |
| Rate for Payer: Aetna Commercial |
$87.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.87
|
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: First Health Commercial |
$108.23
|
| Rate for Payer: Humana Commercial |
$96.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.26
|
| Rate for Payer: Ohio Health Group HMO |
$85.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.32
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
IP
|
$108.03
|
|
| Hospital Charge Code |
636T0123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$103.71 |
| Rate for Payer: Aetna Commercial |
$83.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.26
|
| Rate for Payer: Cash Price |
$54.02
|
| Rate for Payer: Cigna Commercial |
$89.66
|
| Rate for Payer: First Health Commercial |
$102.63
|
| Rate for Payer: Humana Commercial |
$91.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.07
|
| Rate for Payer: Ohio Health Group HMO |
$81.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.49
|
| Rate for Payer: PHCS Commercial |
$103.71
|
| Rate for Payer: United Healthcare All Payer |
$95.07
|
|
|
XYLOCAINE MPF 2% RT TX VI A5ML
|
Facility
|
OP
|
$78.21
|
|
|
Service Code
|
NDC 143959425
|
| Hospital Charge Code |
25003626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$75.08 |
| Rate for Payer: Aetna Commercial |
$60.22
|
| Rate for Payer: Anthem Medicaid |
$26.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.00
|
| Rate for Payer: Cash Price |
$39.10
|
| Rate for Payer: Cigna Commercial |
$64.91
|
| Rate for Payer: First Health Commercial |
$74.30
|
| Rate for Payer: Humana Commercial |
$66.48
|
| Rate for Payer: Humana KY Medicaid |
$26.90
|
| Rate for Payer: Kentucky WC Medicaid |
$27.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.82
|
| Rate for Payer: Ohio Health Group HMO |
$58.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.25
|
| Rate for Payer: PHCS Commercial |
$75.08
|
| Rate for Payer: United Healthcare All Payer |
$68.82
|
|
|
XYLOCAINE MPF 2% RT TX VI A5ML
|
Facility
|
IP
|
$78.21
|
|
|
Service Code
|
NDC 143959425
|
| Hospital Charge Code |
25003626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$75.08 |
| Rate for Payer: Aetna Commercial |
$60.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.00
|
| Rate for Payer: Cash Price |
$39.10
|
| Rate for Payer: Cigna Commercial |
$64.91
|
| Rate for Payer: First Health Commercial |
$74.30
|
| Rate for Payer: Humana Commercial |
$66.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.82
|
| Rate for Payer: Ohio Health Group HMO |
$58.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.25
|
| Rate for Payer: PHCS Commercial |
$75.08
|
| Rate for Payer: United Healthcare All Payer |
$68.82
|
|
|
YEAST DEFINITIVE IDENTIF
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 87106
|
| Hospital Charge Code |
30001276
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
YEAST DEFINITIVE IDENTIF
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 87106
|
| Hospital Charge Code |
30001276
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$10.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.32
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$10.32
|
| Rate for Payer: Humana Medicare Advantage |
$10.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
YERSINIA ENTEROCOLITIEA
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001266
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna Commercial |
$74.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.89
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cigna Commercial |
$80.51
|
| Rate for Payer: First Health Commercial |
$92.15
|
| Rate for Payer: Humana Commercial |
$82.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$79.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$71.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.36
|
| Rate for Payer: Ohio Health Group HMO |
$72.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.07
|
| Rate for Payer: PHCS Commercial |
$93.12
|
| Rate for Payer: United Healthcare All Payer |
$85.36
|
|
|
YERSINIA ENTEROCOLITIEA
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001266
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna Commercial |
$74.69
|
| Rate for Payer: Anthem Medicaid |
$6.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.63
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cigna Commercial |
$80.51
|
| Rate for Payer: First Health Commercial |
$92.15
|
| Rate for Payer: Humana Commercial |
$82.45
|
| Rate for Payer: Humana KY Medicaid |
$6.63
|
| Rate for Payer: Humana Medicare Advantage |
$6.63
|
| Rate for Payer: Kentucky WC Medicaid |
$6.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$79.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$71.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.36
|
| Rate for Payer: Ohio Health Group HMO |
$72.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.07
|
| Rate for Payer: PHCS Commercial |
$93.12
|
| Rate for Payer: United Healthcare All Payer |
$85.36
|
|
|
YERVOY 1mg (200mg Vial)
|
Facility
|
OP
|
$189,727.96
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
25003724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.42 |
| Max. Negotiated Rate |
$182,138.84 |
| Rate for Payer: Aetna Commercial |
$146,090.53
|
| Rate for Payer: Anthem Medicaid |
$65,247.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$172.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147,987.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$241.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$232.77
|
| Rate for Payer: Cash Price |
$94,863.98
|
| Rate for Payer: Cash Price |
$94,863.98
|
| Rate for Payer: Cigna Commercial |
$157,474.21
|
| Rate for Payer: First Health Commercial |
$180,241.56
|
| Rate for Payer: Humana Commercial |
$161,268.77
|
| Rate for Payer: Humana KY Medicaid |
$65,247.45
|
| Rate for Payer: Humana Medicare Advantage |
$172.42
|
| Rate for Payer: Kentucky WC Medicaid |
$65,911.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155,576.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140,019.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$66,556.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$166,960.60
|
| Rate for Payer: Ohio Health Group HMO |
$142,295.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37,945.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,664.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,815.67
|
| Rate for Payer: PHCS Commercial |
$182,138.84
|
| Rate for Payer: United Healthcare All Payer |
$166,960.60
|
|
|
YERVOY 1mg (200mg Vial)
|
Facility
|
IP
|
$189,727.96
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
25003724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24,664.63 |
| Max. Negotiated Rate |
$182,138.84 |
| Rate for Payer: Aetna Commercial |
$146,090.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147,987.81
|
| Rate for Payer: Cash Price |
$94,863.98
|
| Rate for Payer: Cigna Commercial |
$157,474.21
|
| Rate for Payer: First Health Commercial |
$180,241.56
|
| Rate for Payer: Humana Commercial |
$161,268.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155,576.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140,019.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56,918.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$166,960.60
|
| Rate for Payer: Ohio Health Group HMO |
$142,295.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37,945.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,664.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,815.67
|
| Rate for Payer: PHCS Commercial |
$182,138.84
|
| Rate for Payer: United Healthcare All Payer |
$166,960.60
|
|
|
YERVOY 1mg (50mg Vial)
|
Facility
|
IP
|
$47,432.11
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
25003723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,166.17 |
| Max. Negotiated Rate |
$45,534.83 |
| Rate for Payer: Aetna Commercial |
$36,522.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36,997.05
|
| Rate for Payer: Cash Price |
$23,716.06
|
| Rate for Payer: Cigna Commercial |
$39,368.65
|
| Rate for Payer: First Health Commercial |
$45,060.50
|
| Rate for Payer: Humana Commercial |
$40,317.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38,894.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35,004.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14,229.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$41,740.26
|
| Rate for Payer: Ohio Health Group HMO |
$35,574.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,486.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,166.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,703.95
|
| Rate for Payer: PHCS Commercial |
$45,534.83
|
| Rate for Payer: United Healthcare All Payer |
$41,740.26
|
|
