|
MUSTANG BALLOON 5*20*135
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
MUSTANG BALLOON 5*20*135
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
MUTAMYCIN 5 MG [ 20MG/40ML]
|
Facility
|
OP
|
$3,444.29
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002659
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$3,306.52 |
| Rate for Payer: Aetna Commercial |
$2,652.10
|
| Rate for Payer: Anthem Medicaid |
$1,184.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$63.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$88.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$1,722.14
|
| Rate for Payer: Cash Price |
$1,722.14
|
| Rate for Payer: Cigna Commercial |
$2,858.76
|
| Rate for Payer: First Health Commercial |
$3,272.08
|
| Rate for Payer: Humana Commercial |
$2,927.65
|
| Rate for Payer: Humana KY Medicaid |
$1,184.49
|
| Rate for Payer: Humana Medicare Advantage |
$63.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,196.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,208.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,030.98
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$688.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$447.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,067.73
|
| Rate for Payer: PHCS Commercial |
$3,306.52
|
| Rate for Payer: United Healthcare All Payer |
$3,030.98
|
|
|
MUTAMYCIN 5 MG [ 20MG/40ML]
|
Facility
|
IP
|
$3,444.29
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002659
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$447.76 |
| Max. Negotiated Rate |
$3,306.52 |
| Rate for Payer: Aetna Commercial |
$2,652.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.55
|
| Rate for Payer: Cash Price |
$1,722.14
|
| Rate for Payer: Cigna Commercial |
$2,858.76
|
| Rate for Payer: First Health Commercial |
$3,272.08
|
| Rate for Payer: Humana Commercial |
$2,927.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,030.98
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$688.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$447.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,067.73
|
| Rate for Payer: PHCS Commercial |
$3,306.52
|
| Rate for Payer: United Healthcare All Payer |
$3,030.98
|
|
|
MUTAMYCIN (MITOMYCIN) 5MG/10ML
|
Facility
|
OP
|
$1,325.82
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$1,272.79 |
| Rate for Payer: Aetna Commercial |
$1,020.88
|
| Rate for Payer: Anthem Medicaid |
$455.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$63.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$88.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$662.91
|
| Rate for Payer: Cash Price |
$662.91
|
| Rate for Payer: Cigna Commercial |
$1,100.43
|
| Rate for Payer: First Health Commercial |
$1,259.53
|
| Rate for Payer: Humana Commercial |
$1,126.95
|
| Rate for Payer: Humana KY Medicaid |
$455.95
|
| Rate for Payer: Humana Medicare Advantage |
$63.35
|
| Rate for Payer: Kentucky WC Medicaid |
$460.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$465.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.72
|
| Rate for Payer: Ohio Health Group HMO |
$994.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$265.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$172.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$411.00
|
| Rate for Payer: PHCS Commercial |
$1,272.79
|
| Rate for Payer: United Healthcare All Payer |
$1,166.72
|
|
|
MUTAMYCIN (MITOMYCIN) 5MG/10ML
|
Facility
|
IP
|
$1,325.82
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.36 |
| Max. Negotiated Rate |
$1,272.79 |
| Rate for Payer: Aetna Commercial |
$1,020.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.14
|
| Rate for Payer: Cash Price |
$662.91
|
| Rate for Payer: Cigna Commercial |
$1,100.43
|
| Rate for Payer: First Health Commercial |
$1,259.53
|
| Rate for Payer: Humana Commercial |
$1,126.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$397.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.72
|
| Rate for Payer: Ohio Health Group HMO |
$994.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$265.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$172.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$411.00
|
| Rate for Payer: PHCS Commercial |
$1,272.79
|
| Rate for Payer: United Healthcare All Payer |
$1,166.72
|
|
|
M V I W/VITIMIN K
|
Facility
|
OP
|
$122.38
|
|
|
Service Code
|
NDC 54643564901
|
| Hospital Charge Code |
25000936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$117.48 |
| Rate for Payer: Anthem Medicaid |
$42.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.46
|
| Rate for Payer: Cash Price |
$61.19
|
| Rate for Payer: Cigna Commercial |
$101.58
|
| Rate for Payer: First Health Commercial |
$116.26
|
| Rate for Payer: Humana Commercial |
$104.02
|
| Rate for Payer: Humana KY Medicaid |
$42.09
|
| Rate for Payer: Kentucky WC Medicaid |
$42.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.69
|
| Rate for Payer: Ohio Health Group HMO |
$91.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.94
|
| Rate for Payer: PHCS Commercial |
$117.48
|
| Rate for Payer: United Healthcare All Payer |
$107.69
|
| Rate for Payer: Aetna Commercial |
$94.23
|
|
|
M V I W/VITIMIN K
|
Facility
|
IP
|
$122.38
|
|
|
Service Code
|
NDC 54643564901
|
| Hospital Charge Code |
25000936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$117.48 |
| Rate for Payer: Aetna Commercial |
$94.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.46
|
| Rate for Payer: Cash Price |
$61.19
|
| Rate for Payer: Cigna Commercial |
$101.58
|
| Rate for Payer: First Health Commercial |
$116.26
|
| Rate for Payer: Humana Commercial |
$104.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.69
|
| Rate for Payer: Ohio Health Group HMO |
$91.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.94
|
| Rate for Payer: PHCS Commercial |
$117.48
|
| Rate for Payer: United Healthcare All Payer |
$107.69
|
|
|
MYAMBUTOL(ETHAMBUTL)100 MG TAB
|
Facility
|
OP
|
$4.66
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
25001021
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: First Health Commercial |
$4.43
|
| Rate for Payer: Humana Commercial |
$3.96
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.10
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
|
MYAMBUTOL(ETHAMBUTL)100 MG TAB
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
25001021
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Humana Commercial |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.10
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: First Health Commercial |
$4.43
|
|
|
MYAMBUTOL(ETHAMBUTO 400MG/1TAB
|
Facility
|
OP
|
$4.98
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
25001020
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem Medicaid |
$1.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.73
|
| Rate for Payer: Humana Commercial |
$4.23
|
| Rate for Payer: Humana KY Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
MYAMBUTOL(ETHAMBUTO 400MG/1TAB
|
Facility
|
IP
|
$4.98
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
25001020
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.73
|
| Rate for Payer: Humana Commercial |
$4.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.38
|
| Rate for Payer: Ohio Health Group HMO |
$3.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
MYCELEX (CLOTRIMAZOLE 10MG/1EA
|
Facility
|
IP
|
$9.74
|
|
|
Service Code
|
NDC 54414623
|
| Hospital Charge Code |
25001022
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Aetna Commercial |
$7.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.60
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Cigna Commercial |
$8.08
|
| Rate for Payer: First Health Commercial |
$9.25
|
| Rate for Payer: Humana Commercial |
$8.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.57
|
| Rate for Payer: Ohio Health Group HMO |
$7.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$9.35
|
| Rate for Payer: United Healthcare All Payer |
$8.57
|
|
|
MYCELEX (CLOTRIMAZOLE 10MG/1EA
|
Facility
|
OP
|
$9.74
|
|
|
Service Code
|
NDC 54414623
|
| Hospital Charge Code |
25001022
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Aetna Commercial |
$7.50
|
| Rate for Payer: Anthem Medicaid |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.60
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Cigna Commercial |
$8.08
|
| Rate for Payer: First Health Commercial |
$9.25
|
| Rate for Payer: Humana Commercial |
$8.28
|
| Rate for Payer: Humana KY Medicaid |
$3.35
|
| Rate for Payer: Kentucky WC Medicaid |
$3.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.57
|
| Rate for Payer: Ohio Health Group HMO |
$7.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$9.35
|
| Rate for Payer: United Healthcare All Payer |
$8.57
|
|
|
MYCOBUTIN(RIFABUTIN)150MG CAP
|
Facility
|
OP
|
$36.45
|
|
|
Service Code
|
NDC 13530117
|
| Hospital Charge Code |
25001023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Anthem Medicaid |
$12.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.43
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cigna Commercial |
$30.25
|
| Rate for Payer: First Health Commercial |
$34.63
|
| Rate for Payer: Humana Commercial |
$30.98
|
| Rate for Payer: Humana KY Medicaid |
$12.54
|
| Rate for Payer: Kentucky WC Medicaid |
$12.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.08
|
| Rate for Payer: Ohio Health Group HMO |
$27.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.30
|
| Rate for Payer: PHCS Commercial |
$34.99
|
| Rate for Payer: United Healthcare All Payer |
$32.08
|
|
|
MYCOBUTIN(RIFABUTIN)150MG CAP
|
Facility
|
IP
|
$36.45
|
|
|
Service Code
|
NDC 13530117
|
| Hospital Charge Code |
25001023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Aetna Commercial |
$28.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.43
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cigna Commercial |
$30.25
|
| Rate for Payer: First Health Commercial |
$34.63
|
| Rate for Payer: Humana Commercial |
$30.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.08
|
| Rate for Payer: Ohio Health Group HMO |
$27.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.30
|
| Rate for Payer: PHCS Commercial |
$34.99
|
| Rate for Payer: United Healthcare All Payer |
$32.08
|
|
|
MYCOLOG II(NYSTAT/TRIAM)C 15GM
|
Facility
|
OP
|
$6.40
|
|
|
Service Code
|
NDC 45802088014
|
| Hospital Charge Code |
25001025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Humana Commercial |
$5.44
|
| Rate for Payer: Humana KY Medicaid |
$2.20
|
| Rate for Payer: Kentucky WC Medicaid |
$2.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.63
|
| Rate for Payer: Ohio Health Group HMO |
$4.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.98
|
| Rate for Payer: PHCS Commercial |
$6.14
|
| Rate for Payer: United Healthcare All Payer |
$5.63
|
| Rate for Payer: Aetna Commercial |
$4.93
|
| Rate for Payer: Anthem Medicaid |
$2.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.99
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna Commercial |
$5.31
|
| Rate for Payer: First Health Commercial |
$6.08
|
|
|
MYCOLOG II(NYSTAT/TRIAM)C 15GM
|
Facility
|
IP
|
$6.40
|
|
|
Service Code
|
NDC 45802088014
|
| Hospital Charge Code |
25001025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Aetna Commercial |
$4.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.99
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna Commercial |
$5.31
|
| Rate for Payer: First Health Commercial |
$6.08
|
| Rate for Payer: Humana Commercial |
$5.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.63
|
| Rate for Payer: Ohio Health Group HMO |
$4.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.98
|
| Rate for Payer: PHCS Commercial |
$6.14
|
| Rate for Payer: United Healthcare All Payer |
$5.63
|
|
|
MYCOLOG II(NYSTAT/TRIAM)O 15GM
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 62332058515
|
| Hospital Charge Code |
25001026
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna Commercial |
$4.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.98
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cigna Commercial |
$5.30
|
| Rate for Payer: First Health Commercial |
$6.06
|
| Rate for Payer: Humana Commercial |
$5.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.61
|
| Rate for Payer: Ohio Health Group HMO |
$4.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.98
|
| Rate for Payer: PHCS Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Payer |
$5.61
|
|
|
MYCOLOG II(NYSTAT/TRIAM)O 15GM
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 62332058515
|
| Hospital Charge Code |
25001026
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna Commercial |
$4.91
|
| Rate for Payer: Anthem Medicaid |
$2.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.98
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cigna Commercial |
$5.30
|
| Rate for Payer: First Health Commercial |
$6.06
|
| Rate for Payer: Humana Commercial |
$5.42
|
| Rate for Payer: Humana KY Medicaid |
$2.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.61
|
| Rate for Payer: Ohio Health Group HMO |
$4.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.98
|
| Rate for Payer: PHCS Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Payer |
$5.61
|
|
|
MYCOLOG (NYSTATIN/TRIAM) 60GM
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
NDC 68180054503
|
| Hospital Charge Code |
25001024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.53
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna Commercial |
$2.69
|
| Rate for Payer: First Health Commercial |
$3.08
|
| Rate for Payer: Humana Commercial |
$2.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.85
|
| Rate for Payer: Ohio Health Group HMO |
$2.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.00
|
| Rate for Payer: PHCS Commercial |
$3.11
|
| Rate for Payer: United Healthcare All Payer |
$2.85
|
|
|
MYCOLOG (NYSTATIN/TRIAM) 60GM
|
Facility
|
OP
|
$3.24
|
|
|
Service Code
|
NDC 68180054503
|
| Hospital Charge Code |
25001024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Anthem Medicaid |
$1.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.53
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna Commercial |
$2.69
|
| Rate for Payer: First Health Commercial |
$3.08
|
| Rate for Payer: Humana Commercial |
$2.75
|
| Rate for Payer: Humana KY Medicaid |
$1.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.85
|
| Rate for Payer: Ohio Health Group HMO |
$2.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.00
|
| Rate for Payer: PHCS Commercial |
$3.11
|
| Rate for Payer: United Healthcare All Payer |
$2.85
|
|
|
MYCOLOG(NYSTATIN/TRIAM)OI 60GM
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 45802024496
|
| Hospital Charge Code |
25001027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.49
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cigna Commercial |
$2.65
|
| Rate for Payer: First Health Commercial |
$3.03
|
| Rate for Payer: Humana Commercial |
$2.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.81
|
| Rate for Payer: Ohio Health Group HMO |
$2.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.99
|
| Rate for Payer: PHCS Commercial |
$3.06
|
| Rate for Payer: United Healthcare All Payer |
$2.81
|
|
|
MYCOLOG(NYSTATIN/TRIAM)OI 60GM
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 45802024496
|
| Hospital Charge Code |
25001027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Anthem Medicaid |
$1.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.49
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cigna Commercial |
$2.65
|
| Rate for Payer: First Health Commercial |
$3.03
|
| Rate for Payer: Humana Commercial |
$2.71
|
| Rate for Payer: Humana KY Medicaid |
$1.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.81
|
| Rate for Payer: Ohio Health Group HMO |
$2.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.99
|
| Rate for Payer: PHCS Commercial |
$3.06
|
| Rate for Payer: United Healthcare All Payer |
$2.81
|
|
|
MYCOPHENOLATE 200MG/ML SUSP5ML
|
Facility
|
IP
|
$74.25
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
25003764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.65 |
| Max. Negotiated Rate |
$71.28 |
| Rate for Payer: Aetna Commercial |
$57.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.92
|
| Rate for Payer: Cash Price |
$37.12
|
| Rate for Payer: Cigna Commercial |
$61.63
|
| Rate for Payer: First Health Commercial |
$70.54
|
| Rate for Payer: Humana Commercial |
$63.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.34
|
| Rate for Payer: Ohio Health Group HMO |
$55.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.02
|
| Rate for Payer: PHCS Commercial |
$71.28
|
| Rate for Payer: United Healthcare All Payer |
$65.34
|
|
