|
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 |
$24.22 |
| 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 |
$60.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.71
|
| Rate for Payer: PHCS Commercial |
$77.51
|
| Rate for Payer: United Healthcare All Payer |
$71.05
|
|
|
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 |
$24.22 |
| 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 |
$60.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.71
|
| Rate for Payer: PHCS Commercial |
$77.51
|
| Rate for Payer: United Healthcare All Payer |
$71.05
|
|
|
XYLOCAINE(LIDO)[1MG]100MG/5ML
|
Facility
|
IP
|
$115.96
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25002215
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.79 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$89.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.45
|
| Rate for Payer: Cash Price |
$57.98
|
| Rate for Payer: Cigna Commercial |
$96.25
|
| Rate for Payer: First Health Commercial |
$110.16
|
| Rate for Payer: Humana Commercial |
$98.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.04
|
| Rate for Payer: Ohio Health Group HMO |
$86.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.01
|
| Rate for Payer: PHCS Commercial |
$111.32
|
| Rate for Payer: United Healthcare All Payer |
$102.04
|
|
|
XYLOCAINE(LIDO)[1MG]100MG/5ML
|
Facility
|
OP
|
$115.96
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25002215
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.79 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$89.29
|
| Rate for Payer: Anthem Medicaid |
$39.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.45
|
| Rate for Payer: Cash Price |
$57.98
|
| Rate for Payer: Cigna Commercial |
$96.25
|
| Rate for Payer: First Health Commercial |
$110.16
|
| Rate for Payer: Humana Commercial |
$98.57
|
| Rate for Payer: Humana KY Medicaid |
$39.88
|
| Rate for Payer: Kentucky WC Medicaid |
$40.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.04
|
| Rate for Payer: Ohio Health Group HMO |
$86.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.01
|
| Rate for Payer: PHCS Commercial |
$111.32
|
| Rate for Payer: United Healthcare All Payer |
$102.04
|
|
|
XYLOCAINE(LIDOCAINE 250MG/50ML
|
Facility
|
OP
|
$80.32
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.10 |
| 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 |
$64.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.42
|
| Rate for Payer: PHCS Commercial |
$77.11
|
| Rate for Payer: United Healthcare All Payer |
$70.68
|
|
|
XYLOCAINE(LIDOCAINE 250MG/50ML
|
Facility
|
IP
|
$80.32
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
25003628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.10 |
| 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 |
$64.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.42
|
| Rate for Payer: PHCS Commercial |
$77.11
|
| Rate for Payer: United Healthcare All Payer |
$70.68
|
|
|
XYLOCAINE (LIDOCAINE) 2%/50 ML
|
Facility
|
IP
|
$114.13
|
|
|
Service Code
|
NDC 63323048605
|
| Hospital Charge Code |
25003852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.24 |
| 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 |
$91.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.75
|
| Rate for Payer: PHCS Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Payer |
$100.43
|
|
|
XYLOCAINE (LIDOCAINE) 2%/50 ML
|
Facility
|
OP
|
$114.13
|
|
|
Service Code
|
NDC 63323048605
|
| Hospital Charge Code |
25003852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.24 |
| 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 |
$91.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.75
|
| Rate for Payer: PHCS Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Payer |
$100.43
|
|
|
XYLOCAINE (LIDOCAINE) 5% 35GM
|
Facility
|
IP
|
$5.10
|
|
|
Service Code
|
NDC 68462041820
|
| Hospital Charge Code |
25003615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| 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 |
$4.33
|
| 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 |
$3.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.52
|
| Rate for Payer: PHCS Commercial |
$4.90
|
| Rate for Payer: United Healthcare All Payer |
$4.49
|
|
|
XYLOCAINE (LIDOCAINE) 5% 35GM
|
Facility
|
OP
|
$5.10
|
|
|
Service Code
|
NDC 68462041820
|
| Hospital Charge Code |
25003615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
| 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 |
$4.33
|
| 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 |
$3.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.52
|
| Rate for Payer: PHCS Commercial |
$4.90
|
| Rate for Payer: United Healthcare All Payer |
$4.49
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
IP
|
$113.93
|
|
|
Service Code
|
NDC 409428212
|
| Hospital Charge Code |
25004045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| 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 |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
OP
|
$113.93
|
|
|
Service Code
|
NDC 409428212
|
| Hospital Charge Code |
25004045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| 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 |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
IP
|
$113.93
|
|
| Hospital Charge Code |
63600123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| 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 |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
IP
|
$113.93
|
|
| Hospital Charge Code |
636T0123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| 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 |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Professional
|
Both
|
$113.93
|
|
| Hospital Charge Code |
63600123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.88 |
| Max. Negotiated Rate |
$79.75 |
| Rate for Payer: Cash Price |
$56.97
|
| Rate for Payer: Multiplan PHCS |
$68.36
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$79.75
|
| Rate for Payer: UHCCP Medicaid |
$39.88
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
OP
|
$113.93
|
|
| Hospital Charge Code |
636T0123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| 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 |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
XYLOCAINE-MPF 2% AMPUL
|
Facility
|
OP
|
$113.93
|
|
| Hospital Charge Code |
63600123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.18 |
| 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 |
$91.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.61
|
| Rate for Payer: PHCS Commercial |
$109.37
|
| Rate for Payer: United Healthcare All Payer |
$100.26
|
|
|
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 |
$23.46 |
| 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 |
$62.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.96
|
| 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 |
$23.46 |
| 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 |
$62.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.96
|
| Rate for Payer: PHCS Commercial |
$75.08
|
| Rate for Payer: United Healthcare All Payer |
$68.82
|
|
|
YEAST DEFINITIVE IDENTIF
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 87106
|
| Hospital Charge Code |
30001276
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.32 |
| 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 |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
YEAST DEFINITIVE IDENTIF
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 87106
|
| Hospital Charge Code |
30001276
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.70 |
| 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 |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| 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 |
$29.10 |
| 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 |
$77.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.93
|
| 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 |
$77.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.93
|
| Rate for Payer: PHCS Commercial |
$93.12
|
| Rate for Payer: United Healthcare All Payer |
$85.36
|
|
|
YERVOY 1mg (200mg Vial)
|
Facility
|
IP
|
$193,522.52
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
25003724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58,056.76 |
| Max. Negotiated Rate |
$185,781.62 |
| Rate for Payer: Aetna Commercial |
$149,012.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$150,947.57
|
| Rate for Payer: Cash Price |
$96,761.26
|
| Rate for Payer: Cigna Commercial |
$160,623.69
|
| Rate for Payer: First Health Commercial |
$183,846.39
|
| Rate for Payer: Humana Commercial |
$164,494.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$158,688.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$142,819.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58,056.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$170,299.82
|
| Rate for Payer: Ohio Health Group HMO |
$145,141.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154,818.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168,364.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133,530.54
|
| Rate for Payer: PHCS Commercial |
$185,781.62
|
| Rate for Payer: United Healthcare All Payer |
$170,299.82
|
|
|
YERVOY 1mg (200mg Vial)
|
Facility
|
OP
|
$193,522.52
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
25003724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.41 |
| Max. Negotiated Rate |
$185,781.62 |
| Rate for Payer: Aetna Commercial |
$149,012.34
|
| Rate for Payer: Anthem Medicaid |
$66,552.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$150,947.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$256.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.60
|
| Rate for Payer: Cash Price |
$96,761.26
|
| Rate for Payer: Cash Price |
$96,761.26
|
| Rate for Payer: Cigna Commercial |
$160,623.69
|
| Rate for Payer: First Health Commercial |
$183,846.39
|
| Rate for Payer: Humana Commercial |
$164,494.14
|
| Rate for Payer: Humana KY Medicaid |
$66,552.39
|
| Rate for Payer: Humana Medicare Advantage |
$183.41
|
| Rate for Payer: Kentucky WC Medicaid |
$67,229.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$158,688.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$142,819.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$67,887.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$170,299.82
|
| Rate for Payer: Ohio Health Group HMO |
$145,141.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154,818.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168,364.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133,530.54
|
| Rate for Payer: PHCS Commercial |
$185,781.62
|
| Rate for Payer: United Healthcare All Payer |
$170,299.82
|
|
