|
MAVIK (TRANDOLAPRIL) 1MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68180056601
|
| Hospital Charge Code |
25003876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 1MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68180056601
|
| Hospital Charge Code |
25003876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68180056701
|
| Hospital Charge Code |
25000944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68180056701
|
| Hospital Charge Code |
25000944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68180056801
|
| Hospital Charge Code |
25000945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAVIK (TRANDOLAPRIL) 2MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68180056801
|
| Hospital Charge Code |
25000945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
MAXALT-MLT(RIZATRIPTAN)10 MG T
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 65862062690
|
| Hospital Charge Code |
25000948
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXALT-MLT(RIZATRIPTAN)10 MG T
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 65862062690
|
| Hospital Charge Code |
25000948
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXALT-MLT(RIZATRIPTAN) 5MGTAB
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 65862062590
|
| Hospital Charge Code |
25000947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXALT-MLT(RIZATRIPTAN) 5MGTAB
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 65862062590
|
| Hospital Charge Code |
25000947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
MAXIMO II VR D284VRC
|
Facility
|
OP
|
$82,700.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
27000004
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$24,810.00 |
| Max. Negotiated Rate |
$79,392.00 |
| Rate for Payer: Aetna Commercial |
$63,679.00
|
| Rate for Payer: Anthem Medicaid |
$28,440.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64,506.00
|
| Rate for Payer: Cash Price |
$41,350.00
|
| Rate for Payer: Cigna Commercial |
$68,641.00
|
| Rate for Payer: First Health Commercial |
$78,565.00
|
| Rate for Payer: Humana Commercial |
$70,295.00
|
| Rate for Payer: Humana KY Medicaid |
$28,440.53
|
| Rate for Payer: Kentucky WC Medicaid |
$28,729.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67,814.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,032.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,810.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,011.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$72,776.00
|
| Rate for Payer: Ohio Health Group HMO |
$62,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71,949.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57,063.00
|
| Rate for Payer: PHCS Commercial |
$79,392.00
|
| Rate for Payer: United Healthcare All Payer |
$72,776.00
|
|
|
MAXIMO II VR D284VRC
|
Facility
|
IP
|
$82,700.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
27000004
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$24,810.00 |
| Max. Negotiated Rate |
$79,392.00 |
| Rate for Payer: Aetna Commercial |
$63,679.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64,506.00
|
| Rate for Payer: Cash Price |
$41,350.00
|
| Rate for Payer: Cigna Commercial |
$68,641.00
|
| Rate for Payer: First Health Commercial |
$78,565.00
|
| Rate for Payer: Humana Commercial |
$70,295.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67,814.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,032.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,810.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$72,776.00
|
| Rate for Payer: Ohio Health Group HMO |
$62,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71,949.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57,063.00
|
| Rate for Payer: PHCS Commercial |
$79,392.00
|
| Rate for Payer: United Healthcare All Payer |
$72,776.00
|
|
|
MAXIPIME 1 GM/ 3.6 ML
|
Facility
|
IP
|
$73.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.14 |
| Max. Negotiated Rate |
$70.85 |
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$61.25
|
| Rate for Payer: First Health Commercial |
$70.11
|
| Rate for Payer: Humana Commercial |
$62.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.94
|
| Rate for Payer: Ohio Health Group HMO |
$55.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.92
|
| Rate for Payer: PHCS Commercial |
$70.85
|
| Rate for Payer: United Healthcare All Payer |
$64.94
|
|
|
MAXIPIME 1 GM/ 3.6 ML
|
Facility
|
OP
|
$73.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.14 |
| Max. Negotiated Rate |
$70.85 |
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Anthem Medicaid |
$25.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$61.25
|
| Rate for Payer: First Health Commercial |
$70.11
|
| Rate for Payer: Humana Commercial |
$62.73
|
| Rate for Payer: Humana KY Medicaid |
$25.38
|
| Rate for Payer: Kentucky WC Medicaid |
$25.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.94
|
| Rate for Payer: Ohio Health Group HMO |
$55.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.92
|
| Rate for Payer: PHCS Commercial |
$70.85
|
| Rate for Payer: United Healthcare All Payer |
$64.94
|
|
|
MAXIPIME 2GM/20ML VIAL
|
Facility
|
IP
|
$121.13
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.34 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.48
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.54
|
| Rate for Payer: First Health Commercial |
$115.07
|
| Rate for Payer: Humana Commercial |
$102.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.58
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
MAXIPIME 2GM/20ML VIAL
|
Facility
|
OP
|
$121.13
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25003922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.34 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.27
|
| Rate for Payer: Anthem Medicaid |
$41.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.48
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.54
|
| Rate for Payer: First Health Commercial |
$115.07
|
| Rate for Payer: Humana Commercial |
$102.96
|
| Rate for Payer: Humana KY Medicaid |
$41.66
|
| Rate for Payer: Kentucky WC Medicaid |
$42.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.58
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
MAXIPIME 500 MG (1 GRAM VIAL)
|
Facility
|
OP
|
$112.05
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem Medicaid |
$38.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Humana KY Medicaid |
$38.53
|
| Rate for Payer: Kentucky WC Medicaid |
$38.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.31
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
|
MAXIPIME 500 MG (1 GRAM VIAL)
|
Facility
|
IP
|
$112.05
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.31
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
|
MAXIPIME 500MG [2GM SYRINGE]
|
Facility
|
IP
|
$116.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.04 |
| Max. Negotiated Rate |
$112.13 |
| Rate for Payer: Aetna Commercial |
$89.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.10
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cigna Commercial |
$96.94
|
| Rate for Payer: First Health Commercial |
$110.96
|
| Rate for Payer: Humana Commercial |
$99.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.78
|
| Rate for Payer: Ohio Health Group HMO |
$87.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.59
|
| Rate for Payer: PHCS Commercial |
$112.13
|
| Rate for Payer: United Healthcare All Payer |
$102.78
|
|
|
MAXIPIME 500MG [2GM SYRINGE]
|
Facility
|
OP
|
$116.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.04 |
| Max. Negotiated Rate |
$112.13 |
| Rate for Payer: Aetna Commercial |
$89.94
|
| Rate for Payer: Anthem Medicaid |
$40.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.10
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cigna Commercial |
$96.94
|
| Rate for Payer: First Health Commercial |
$110.96
|
| Rate for Payer: Humana Commercial |
$99.28
|
| Rate for Payer: Humana KY Medicaid |
$40.17
|
| Rate for Payer: Kentucky WC Medicaid |
$40.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.78
|
| Rate for Payer: Ohio Health Group HMO |
$87.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.59
|
| Rate for Payer: PHCS Commercial |
$112.13
|
| Rate for Payer: United Healthcare All Payer |
$102.78
|
|
|
MAXITROL (COMB) OPHTH OI 3.5GM
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
25000950
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Anthem Medicaid |
$1.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.36
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna Commercial |
$2.51
|
| Rate for Payer: First Health Commercial |
$2.88
|
| Rate for Payer: Humana Commercial |
$2.58
|
| Rate for Payer: Humana KY Medicaid |
$1.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.67
|
| Rate for Payer: Ohio Health Group HMO |
$2.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.09
|
| Rate for Payer: PHCS Commercial |
$2.91
|
| Rate for Payer: United Healthcare All Payer |
$2.67
|
|
|
MAXITROL (COMB) OPHTH OI 3.5GM
|
Facility
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
25000950
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.36
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna Commercial |
$2.51
|
| Rate for Payer: First Health Commercial |
$2.88
|
| Rate for Payer: Humana Commercial |
$2.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.67
|
| Rate for Payer: Ohio Health Group HMO |
$2.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.09
|
| Rate for Payer: PHCS Commercial |
$2.91
|
| Rate for Payer: United Healthcare All Payer |
$2.67
|
|
|
MAXITROL (NEO/POLY/DEX)OPH 5ML
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 24208083060
|
| Hospital Charge Code |
25000951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.70
|
| Rate for Payer: Anthem Medicaid |
$0.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.86
|
| Rate for Payer: Humana Commercial |
$0.77
|
| Rate for Payer: Humana KY Medicaid |
$0.31
|
| Rate for Payer: Kentucky WC Medicaid |
$0.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.80
|
| Rate for Payer: Ohio Health Group HMO |
$0.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.63
|
| Rate for Payer: PHCS Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Payer |
$0.80
|
|
|
MAXITROL (NEO/POLY/DEX)OPH 5ML
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 24208083060
|
| Hospital Charge Code |
25000951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.86
|
| Rate for Payer: Humana Commercial |
$0.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.80
|
| Rate for Payer: Ohio Health Group HMO |
$0.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.63
|
| Rate for Payer: PHCS Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Payer |
$0.80
|
|
|
MAXZIDE(TRIAM/HCTZ) 37.5M 1TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 68001032700
|
| Hospital Charge Code |
25000952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
