|
MYAMBUTOL(ETHAMBUTL)100 MG TAB
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
25001021
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.47 |
| 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
|
| 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 |
$3.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
|
MYAMBUTOL(ETHAMBUTL)100 MG TAB
|
Facility
|
OP
|
$4.66
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
25001021
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| 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 |
$3.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
|
MYAMBUTOL(ETHAMBUTO 400MG/1TAB
|
Facility
|
IP
|
$4.98
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
25001020
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
MYAMBUTOL(ETHAMBUTO 400MG/1TAB
|
Facility
|
OP
|
$4.98
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
25001020
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.44
|
| Rate for Payer: PHCS Commercial |
$4.78
|
| Rate for Payer: United Healthcare All Payer |
$4.38
|
|
|
MYCELEX (CLOTRIMAZOLE 10MG/1EA
|
Facility
|
OP
|
$9.74
|
|
|
Service Code
|
NDC 54414623
|
| Hospital Charge Code |
25001022
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.92 |
| 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 |
$7.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.72
|
| Rate for Payer: PHCS Commercial |
$9.35
|
| Rate for Payer: United Healthcare All Payer |
$8.57
|
|
|
MYCELEX (CLOTRIMAZOLE 10MG/1EA
|
Facility
|
IP
|
$9.74
|
|
|
Service Code
|
NDC 54414623
|
| Hospital Charge Code |
25001022
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.92 |
| 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 |
$7.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.72
|
| 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 |
$10.94 |
| 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 |
$29.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.15
|
| 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 |
$10.94 |
| 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 |
$29.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.15
|
| 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 |
$1.92 |
| Max. Negotiated Rate |
$6.14 |
| 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
|
| 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 |
$5.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.42
|
| Rate for Payer: PHCS Commercial |
$6.14
|
| Rate for Payer: United Healthcare All Payer |
$5.63
|
|
|
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 |
$1.92 |
| 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 |
$5.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.42
|
| Rate for Payer: PHCS Commercial |
$6.14
|
| Rate for Payer: United Healthcare All Payer |
$5.63
|
|
|
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 |
$1.91 |
| 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 |
$4.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.40
|
| Rate for Payer: PHCS Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Payer |
$5.61
|
|
|
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 |
$1.91 |
| 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 |
$4.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.40
|
| Rate for Payer: PHCS Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Payer |
$5.61
|
|
|
MYCOLOG (NYSTATIN/TRIAM) 60GM
|
Facility
|
OP
|
$3.24
|
|
|
Service Code
|
NDC 68180054503
|
| Hospital Charge Code |
25001024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| 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 |
$2.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.24
|
| Rate for Payer: PHCS Commercial |
$3.11
|
| Rate for Payer: United Healthcare All Payer |
$2.85
|
|
|
MYCOLOG (NYSTATIN/TRIAM) 60GM
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
NDC 68180054503
|
| Hospital Charge Code |
25001024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| 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 |
$2.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.24
|
| Rate for Payer: PHCS Commercial |
$3.11
|
| Rate for Payer: United Healthcare All Payer |
$2.85
|
|
|
MYCOLOG(NYSTATIN/TRIAM)OI 60GM
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 45802024496
|
| Hospital Charge Code |
25001027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| 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 |
$2.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.20
|
| Rate for Payer: PHCS Commercial |
$3.06
|
| Rate for Payer: United Healthcare All Payer |
$2.81
|
|
|
MYCOLOG(NYSTATIN/TRIAM)OI 60GM
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 45802024496
|
| Hospital Charge Code |
25001027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| 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 |
$2.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.20
|
| Rate for Payer: PHCS Commercial |
$3.06
|
| Rate for Payer: United Healthcare All Payer |
$2.81
|
|
|
MYCOPHENOLATE 200MG/ML SUSP5ML
|
Facility
|
OP
|
$74.25
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
25003764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$71.28 |
| Rate for Payer: Aetna Commercial |
$57.17
|
| Rate for Payer: Anthem Medicaid |
$25.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.91
|
| 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: Humana KY Medicaid |
$25.53
|
| Rate for Payer: Kentucky WC Medicaid |
$25.79
|
| 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 |
$22.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.05
|
| 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 |
$59.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.23
|
| Rate for Payer: PHCS Commercial |
$71.28
|
| Rate for Payer: United Healthcare All Payer |
$65.34
|
|
|
MYCOPHENOLATE 200MG/ML SUSP5ML
|
Facility
|
IP
|
$74.25
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
25003764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$71.28 |
| Rate for Payer: Aetna Commercial |
$57.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.91
|
| 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 |
$22.27
|
| 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 |
$59.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.23
|
| Rate for Payer: PHCS Commercial |
$71.28
|
| Rate for Payer: United Healthcare All Payer |
$65.34
|
|
|
MYCOPLASMA GENITALIUM PCR
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS 87798
|
| Hospital Charge Code |
30001404
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$79.20 |
| Max. Negotiated Rate |
$253.44 |
| Rate for Payer: Aetna Commercial |
$203.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$211.99
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$219.12
|
| Rate for Payer: First Health Commercial |
$250.80
|
| Rate for Payer: Humana Commercial |
$224.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$216.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$194.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$232.32
|
| Rate for Payer: Ohio Health Group HMO |
$198.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$182.16
|
| Rate for Payer: PHCS Commercial |
$253.44
|
| Rate for Payer: United Healthcare All Payer |
$232.32
|
|
|
MYCOPLASMA GENITALIUM PCR
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS 87798
|
| Hospital Charge Code |
30001404
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$253.44 |
| Rate for Payer: Aetna Commercial |
$203.28
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$211.99
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$219.12
|
| Rate for Payer: First Health Commercial |
$250.80
|
| Rate for Payer: Humana Commercial |
$224.40
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$216.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$194.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$232.32
|
| Rate for Payer: Ohio Health Group HMO |
$198.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$182.16
|
| Rate for Payer: PHCS Commercial |
$253.44
|
| Rate for Payer: United Healthcare All Payer |
$232.32
|
|
|
MYCOPLASMA PNEUMONIAE MOL DET
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 87581
|
| Hospital Charge Code |
30001383
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.28
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.63
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
MYCOPLASMA PNEUMONIAE MOL DET
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 87581
|
| Hospital Charge Code |
30001383
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.63
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
MYCOSTATIN(NYSTATIN)1000 15GM
|
Facility
|
IP
|
$5.80
|
|
|
Service Code
|
NDC 72578008901
|
| Hospital Charge Code |
25001030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Aetna Commercial |
$4.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna Commercial |
$4.81
|
| Rate for Payer: First Health Commercial |
$5.51
|
| Rate for Payer: Humana Commercial |
$4.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.10
|
| Rate for Payer: Ohio Health Group HMO |
$4.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.00
|
| Rate for Payer: PHCS Commercial |
$5.57
|
| Rate for Payer: United Healthcare All Payer |
$5.10
|
|
|
MYCOSTATIN(NYSTATIN)1000 15GM
|
Facility
|
OP
|
$5.80
|
|
|
Service Code
|
NDC 72578008901
|
| Hospital Charge Code |
25001030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Aetna Commercial |
$4.47
|
| Rate for Payer: Anthem Medicaid |
$1.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.52
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna Commercial |
$4.81
|
| Rate for Payer: First Health Commercial |
$5.51
|
| Rate for Payer: Humana Commercial |
$4.93
|
| Rate for Payer: Humana KY Medicaid |
$1.99
|
| Rate for Payer: Kentucky WC Medicaid |
$2.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.10
|
| Rate for Payer: Ohio Health Group HMO |
$4.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.00
|
| Rate for Payer: PHCS Commercial |
$5.57
|
| Rate for Payer: United Healthcare All Payer |
$5.10
|
|
|
MYCOSTATIN (NYSTATIN)100 15GM
|
Facility
|
IP
|
$5.87
|
|
|
Service Code
|
NDC 713067815
|
| Hospital Charge Code |
25001028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna Commercial |
$4.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.58
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna Commercial |
$4.87
|
| Rate for Payer: First Health Commercial |
$5.58
|
| Rate for Payer: Humana Commercial |
$4.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.17
|
| Rate for Payer: Ohio Health Group HMO |
$4.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.05
|
| Rate for Payer: PHCS Commercial |
$5.64
|
| Rate for Payer: United Healthcare All Payer |
$5.17
|
|
