|
METROGEL-VAGINAL(METRONID 70GM
|
Facility
|
IP
|
$54.54
|
|
|
Service Code
|
NDC 45802013970
|
| Hospital Charge Code |
25000974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$52.36 |
| Rate for Payer: Aetna Commercial |
$42.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.54
|
| Rate for Payer: Cash Price |
$27.27
|
| Rate for Payer: Cigna Commercial |
$45.27
|
| Rate for Payer: First Health Commercial |
$51.81
|
| Rate for Payer: Humana Commercial |
$46.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.00
|
| Rate for Payer: Ohio Health Group HMO |
$40.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.91
|
| Rate for Payer: PHCS Commercial |
$52.36
|
| Rate for Payer: United Healthcare All Payer |
$48.00
|
|
|
METROGEL-VAGINAL(METRONID 70GM
|
Facility
|
OP
|
$54.54
|
|
|
Service Code
|
NDC 45802013970
|
| Hospital Charge Code |
25000974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$52.36 |
| Rate for Payer: Aetna Commercial |
$42.00
|
| Rate for Payer: Anthem Medicaid |
$18.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.54
|
| Rate for Payer: Cash Price |
$27.27
|
| Rate for Payer: Cigna Commercial |
$45.27
|
| Rate for Payer: First Health Commercial |
$51.81
|
| Rate for Payer: Humana Commercial |
$46.36
|
| Rate for Payer: Humana KY Medicaid |
$18.76
|
| Rate for Payer: Kentucky WC Medicaid |
$18.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.00
|
| Rate for Payer: Ohio Health Group HMO |
$40.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.91
|
| Rate for Payer: PHCS Commercial |
$52.36
|
| Rate for Payer: United Healthcare All Payer |
$48.00
|
|
|
METRONIDAZOLE 0.75% CRM 45G
|
Facility
|
IP
|
$6.81
|
|
|
Service Code
|
NDC 168032346
|
| Hospital Charge Code |
25000975
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$6.54 |
| Rate for Payer: Aetna Commercial |
$5.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.31
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cigna Commercial |
$5.65
|
| Rate for Payer: First Health Commercial |
$6.47
|
| Rate for Payer: Humana Commercial |
$5.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.99
|
| Rate for Payer: Ohio Health Group HMO |
$5.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.11
|
| Rate for Payer: PHCS Commercial |
$6.54
|
| Rate for Payer: United Healthcare All Payer |
$5.99
|
|
|
METRONIDAZOLE 0.75% CRM 45G
|
Facility
|
OP
|
$6.81
|
|
|
Service Code
|
NDC 168032346
|
| Hospital Charge Code |
25000975
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$6.54 |
| Rate for Payer: Aetna Commercial |
$5.24
|
| Rate for Payer: Anthem Medicaid |
$2.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.31
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cigna Commercial |
$5.65
|
| Rate for Payer: First Health Commercial |
$6.47
|
| Rate for Payer: Humana Commercial |
$5.79
|
| Rate for Payer: Humana KY Medicaid |
$2.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.99
|
| Rate for Payer: Ohio Health Group HMO |
$5.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.11
|
| Rate for Payer: PHCS Commercial |
$6.54
|
| Rate for Payer: United Healthcare All Payer |
$5.99
|
|
|
METRONIDAZOLE 10mg (500mg bag)
|
Facility
|
OP
|
$78.68
|
|
|
Service Code
|
HCPCS J1836
|
| Hospital Charge Code |
25003067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$75.53 |
| Rate for Payer: Aetna Commercial |
$60.58
|
| Rate for Payer: Anthem Medicaid |
$27.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.37
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$39.34
|
| Rate for Payer: Cash Price |
$39.34
|
| Rate for Payer: Cigna Commercial |
$65.30
|
| Rate for Payer: First Health Commercial |
$74.75
|
| Rate for Payer: Humana Commercial |
$66.88
|
| Rate for Payer: Humana KY Medicaid |
$27.06
|
| Rate for Payer: Humana Medicare Advantage |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$27.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.24
|
| Rate for Payer: Ohio Health Group HMO |
$59.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.39
|
| Rate for Payer: PHCS Commercial |
$75.53
|
| Rate for Payer: United Healthcare All Payer |
$69.24
|
|
|
METRONIDAZOLE 10mg (500mg bag)
|
Facility
|
IP
|
$78.68
|
|
|
Service Code
|
HCPCS J1836
|
| Hospital Charge Code |
25003067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$75.53 |
| Rate for Payer: Aetna Commercial |
$60.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.37
|
| Rate for Payer: Cash Price |
$39.34
|
| Rate for Payer: Cigna Commercial |
$65.30
|
| Rate for Payer: First Health Commercial |
$74.75
|
| Rate for Payer: Humana Commercial |
$66.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.24
|
| Rate for Payer: Ohio Health Group HMO |
$59.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.39
|
| Rate for Payer: PHCS Commercial |
$75.53
|
| Rate for Payer: United Healthcare All Payer |
$69.24
|
|
|
METRONIDAZOLE 1% TOPGEL 60 GM
|
Facility
|
IP
|
$9.55
|
|
|
Service Code
|
NDC 51672421503
|
| Hospital Charge Code |
25000976
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Aetna Commercial |
$7.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.45
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna Commercial |
$7.93
|
| Rate for Payer: First Health Commercial |
$9.07
|
| Rate for Payer: Humana Commercial |
$8.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.40
|
| Rate for Payer: Ohio Health Group HMO |
$7.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.96
|
| Rate for Payer: PHCS Commercial |
$9.17
|
| Rate for Payer: United Healthcare All Payer |
$8.40
|
|
|
METRONIDAZOLE 1% TOPGEL 60 GM
|
Facility
|
OP
|
$9.55
|
|
|
Service Code
|
NDC 51672421503
|
| Hospital Charge Code |
25000976
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Humana Commercial |
$8.12
|
| Rate for Payer: Humana KY Medicaid |
$3.28
|
| Rate for Payer: Kentucky WC Medicaid |
$3.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.40
|
| Rate for Payer: Ohio Health Group HMO |
$7.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.96
|
| Rate for Payer: PHCS Commercial |
$9.17
|
| Rate for Payer: United Healthcare All Payer |
$8.40
|
| Rate for Payer: Aetna Commercial |
$7.35
|
| Rate for Payer: Anthem Medicaid |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.45
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna Commercial |
$7.93
|
| Rate for Payer: First Health Commercial |
$9.07
|
|
|
MEVACOR 20MG 1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 68084055901
|
| Hospital Charge Code |
25000977
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
MEVACOR 20MG 1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 68084055901
|
| Hospital Charge Code |
25000977
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
MEXITIL (MEXILETINE 150MG/1CAP
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
NDC 50742023901
|
| Hospital Charge Code |
25000978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MEXITIL (MEXILETINE 150MG/1CAP
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
NDC 50742023901
|
| Hospital Charge Code |
25000978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MEXITIL (MEXILETINE 200MG/1CAP
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 50742024001
|
| Hospital Charge Code |
25000979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
MEXITIL (MEXILETINE 200MG/1CAP
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
NDC 50742024001
|
| Hospital Charge Code |
25000979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
MIACALCIN (CALCI/S 200IU/1SPRA
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 60505082306
|
| Hospital Charge Code |
25000980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
MIACALCIN (CALCI/S 200IU/1SPRA
|
Facility
|
OP
|
$10.33
|
|
|
Service Code
|
NDC 60505082306
|
| Hospital Charge Code |
25000980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem Medicaid |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Humana KY Medicaid |
$3.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
MICAFUNGIN 1MG(50MG) SDV
|
Facility
|
IP
|
$362.50
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
25004529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$279.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.75
|
| Rate for Payer: Cash Price |
$181.25
|
| Rate for Payer: Cigna Commercial |
$300.88
|
| Rate for Payer: First Health Commercial |
$344.38
|
| Rate for Payer: Humana Commercial |
$308.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.00
|
| Rate for Payer: Ohio Health Group HMO |
$271.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.38
|
| Rate for Payer: PHCS Commercial |
$348.00
|
| Rate for Payer: United Healthcare All Payer |
$319.00
|
|
|
MICAFUNGIN 1MG(50MG) SDV
|
Facility
|
OP
|
$362.50
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
25004529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$279.12
|
| Rate for Payer: Anthem Medicaid |
$124.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$282.75
|
| Rate for Payer: Cash Price |
$181.25
|
| Rate for Payer: Cigna Commercial |
$300.88
|
| Rate for Payer: First Health Commercial |
$344.38
|
| Rate for Payer: Humana Commercial |
$308.12
|
| Rate for Payer: Humana KY Medicaid |
$124.66
|
| Rate for Payer: Kentucky WC Medicaid |
$125.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$297.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.00
|
| Rate for Payer: Ohio Health Group HMO |
$271.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.38
|
| Rate for Payer: PHCS Commercial |
$348.00
|
| Rate for Payer: United Healthcare All Payer |
$319.00
|
|
|
MICARDIS 20MG TABLET
|
Facility
|
IP
|
$12.68
|
|
|
Service Code
|
NDC 597003937
|
| Hospital Charge Code |
25000981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$12.17 |
| Rate for Payer: Aetna Commercial |
$9.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.89
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: First Health Commercial |
$12.05
|
| Rate for Payer: Humana Commercial |
$10.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.16
|
| Rate for Payer: Ohio Health Group HMO |
$9.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.93
|
| Rate for Payer: PHCS Commercial |
$12.17
|
| Rate for Payer: United Healthcare All Payer |
$11.16
|
|
|
MICARDIS 20MG TABLET
|
Facility
|
OP
|
$12.68
|
|
|
Service Code
|
NDC 597003937
|
| Hospital Charge Code |
25000981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$12.17 |
| Rate for Payer: Aetna Commercial |
$9.76
|
| Rate for Payer: Anthem Medicaid |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.89
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: First Health Commercial |
$12.05
|
| Rate for Payer: Humana Commercial |
$10.78
|
| Rate for Payer: Humana KY Medicaid |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.16
|
| Rate for Payer: Ohio Health Group HMO |
$9.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.93
|
| Rate for Payer: PHCS Commercial |
$12.17
|
| Rate for Payer: United Healthcare All Payer |
$11.16
|
|
|
MICARDIS 40 MG TABLET
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 68382047278
|
| Hospital Charge Code |
25000982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Humana KY Medicaid |
$3.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
MICARDIS 40 MG TABLET
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 68382047278
|
| Hospital Charge Code |
25000982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
MIC G-TUBE 18FR
|
Facility
|
OP
|
$744.76
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
27000186
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$96.82 |
| Max. Negotiated Rate |
$714.97 |
| Rate for Payer: Aetna Commercial |
$573.47
|
| Rate for Payer: Anthem Medicaid |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$580.91
|
| Rate for Payer: Cash Price |
$372.38
|
| Rate for Payer: Cigna Commercial |
$618.15
|
| Rate for Payer: First Health Commercial |
$707.52
|
| Rate for Payer: Humana Commercial |
$633.05
|
| Rate for Payer: Humana KY Medicaid |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$258.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$610.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$549.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$223.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$261.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$655.39
|
| Rate for Payer: Ohio Health Group HMO |
$558.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$230.88
|
| Rate for Payer: PHCS Commercial |
$714.97
|
| Rate for Payer: United Healthcare All Payer |
$655.39
|
|
|
MIC G-TUBE 18FR
|
Facility
|
IP
|
$744.76
|
|
|
Service Code
|
HCPCS B4087
|
| Hospital Charge Code |
27000186
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$96.82 |
| Max. Negotiated Rate |
$714.97 |
| Rate for Payer: Aetna Commercial |
$573.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$580.91
|
| Rate for Payer: Cash Price |
$372.38
|
| Rate for Payer: Cigna Commercial |
$618.15
|
| Rate for Payer: First Health Commercial |
$707.52
|
| Rate for Payer: Humana Commercial |
$633.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$610.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$549.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$223.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$655.39
|
| Rate for Payer: Ohio Health Group HMO |
$558.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$230.88
|
| Rate for Payer: PHCS Commercial |
$714.97
|
| Rate for Payer: United Healthcare All Payer |
$655.39
|
|
|
MIC J-TUBE 18FR 2.3*30CM KIT
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS B4088
|
| Hospital Charge Code |
27000187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
