|
NIRXCELL STENT 4.0*28
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 4.0*33
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 4.0*33
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 4.0*8
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 4.0*8
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NISOLDIPINE 25.5MG ER TABLET
|
Facility
|
IP
|
$23.30
|
|
|
Service Code
|
NDC 378209801
|
| Hospital Charge Code |
25003274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$22.37 |
| Rate for Payer: Aetna Commercial |
$17.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.17
|
| Rate for Payer: Cash Price |
$11.65
|
| Rate for Payer: Cigna Commercial |
$19.34
|
| Rate for Payer: First Health Commercial |
$22.14
|
| Rate for Payer: Humana Commercial |
$19.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.50
|
| Rate for Payer: Ohio Health Group HMO |
$17.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.22
|
| Rate for Payer: PHCS Commercial |
$22.37
|
| Rate for Payer: United Healthcare All Payer |
$20.50
|
|
|
NISOLDIPINE 25.5MG ER TABLET
|
Facility
|
OP
|
$23.30
|
|
|
Service Code
|
NDC 378209801
|
| Hospital Charge Code |
25003274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$22.37 |
| Rate for Payer: Aetna Commercial |
$17.94
|
| Rate for Payer: Anthem Medicaid |
$8.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.17
|
| Rate for Payer: Cash Price |
$11.65
|
| Rate for Payer: Cigna Commercial |
$19.34
|
| Rate for Payer: First Health Commercial |
$22.14
|
| Rate for Payer: Humana Commercial |
$19.80
|
| Rate for Payer: Humana KY Medicaid |
$8.01
|
| Rate for Payer: Kentucky WC Medicaid |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.50
|
| Rate for Payer: Ohio Health Group HMO |
$17.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.22
|
| Rate for Payer: PHCS Commercial |
$22.37
|
| Rate for Payer: United Healthcare All Payer |
$20.50
|
|
|
NISOLDIPINE 30MG ER TABLET
|
Facility
|
OP
|
$31.35
|
|
|
Service Code
|
NDC 378222301
|
| Hospital Charge Code |
25003275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$30.10 |
| Rate for Payer: Aetna Commercial |
$24.14
|
| Rate for Payer: Anthem Medicaid |
$10.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.45
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cigna Commercial |
$26.02
|
| Rate for Payer: First Health Commercial |
$29.78
|
| Rate for Payer: Humana Commercial |
$26.65
|
| Rate for Payer: Humana KY Medicaid |
$10.78
|
| Rate for Payer: Kentucky WC Medicaid |
$10.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.59
|
| Rate for Payer: Ohio Health Group HMO |
$23.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.72
|
| Rate for Payer: PHCS Commercial |
$30.10
|
| Rate for Payer: United Healthcare All Payer |
$27.59
|
|
|
NISOLDIPINE 30MG ER TABLET
|
Facility
|
IP
|
$31.35
|
|
|
Service Code
|
NDC 378222301
|
| Hospital Charge Code |
25003275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$30.10 |
| Rate for Payer: Aetna Commercial |
$24.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.45
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cigna Commercial |
$26.02
|
| Rate for Payer: First Health Commercial |
$29.78
|
| Rate for Payer: Humana Commercial |
$26.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.59
|
| Rate for Payer: Ohio Health Group HMO |
$23.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.72
|
| Rate for Payer: PHCS Commercial |
$30.10
|
| Rate for Payer: United Healthcare All Payer |
$27.59
|
|
|
NITRO BID 2% OINTMENT 30GM
|
Facility
|
OP
|
$6.28
|
|
|
Service Code
|
NDC 281032630
|
| Hospital Charge Code |
25003276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$6.03 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Anthem Medicaid |
$2.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.90
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna Commercial |
$5.21
|
| Rate for Payer: First Health Commercial |
$5.97
|
| Rate for Payer: Humana Commercial |
$5.34
|
| Rate for Payer: Humana KY Medicaid |
$2.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.53
|
| Rate for Payer: Ohio Health Group HMO |
$4.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.95
|
| Rate for Payer: PHCS Commercial |
$6.03
|
| Rate for Payer: United Healthcare All Payer |
$5.53
|
|
|
NITRO BID 2% OINTMENT 30GM
|
Facility
|
IP
|
$6.28
|
|
|
Service Code
|
NDC 281032630
|
| Hospital Charge Code |
25003276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$6.03 |
| Rate for Payer: Humana Commercial |
$5.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.53
|
| Rate for Payer: Ohio Health Group HMO |
$4.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.95
|
| Rate for Payer: PHCS Commercial |
$6.03
|
| Rate for Payer: United Healthcare All Payer |
$5.53
|
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.90
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna Commercial |
$5.21
|
| Rate for Payer: First Health Commercial |
$5.97
|
|
|
NITROGLYCERIN 0.1 MG 2.5MG/1EA
|
Facility
|
OP
|
$4.81
|
|
|
Service Code
|
NDC 378910293
|
| Hospital Charge Code |
25001086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.99
|
| Rate for Payer: First Health Commercial |
$4.57
|
| Rate for Payer: Humana Commercial |
$4.09
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.23
|
| Rate for Payer: Ohio Health Group HMO |
$3.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$4.23
|
|
|
NITROGLYCERIN 0.1 MG 2.5MG/1EA
|
Facility
|
IP
|
$4.81
|
|
|
Service Code
|
NDC 378910293
|
| Hospital Charge Code |
25001086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.99
|
| Rate for Payer: First Health Commercial |
$4.57
|
| Rate for Payer: Humana Commercial |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.23
|
| Rate for Payer: Ohio Health Group HMO |
$3.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$4.23
|
|
|
NITROGLYCERIN 0.2 MG/H 5MG/1EA
|
Facility
|
OP
|
$4.91
|
|
|
Service Code
|
NDC 378910493
|
| Hospital Charge Code |
25003278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
|
|
NITROGLYCERIN 0.2 MG/H 5MG/1EA
|
Facility
|
IP
|
$4.91
|
|
|
Service Code
|
NDC 378910493
|
| Hospital Charge Code |
25003278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
|
|
NITROGLYCERIN 0.3 MG 7.5MG/1EA
|
Facility
|
IP
|
$124.99
|
|
|
Service Code
|
NDC 50742051530
|
| Hospital Charge Code |
25001087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$119.99 |
| Rate for Payer: Aetna Commercial |
$96.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.49
|
| Rate for Payer: Cash Price |
$62.49
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: First Health Commercial |
$118.74
|
| Rate for Payer: Humana Commercial |
$106.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.99
|
| Rate for Payer: Ohio Health Group HMO |
$93.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.75
|
| Rate for Payer: PHCS Commercial |
$119.99
|
| Rate for Payer: United Healthcare All Payer |
$109.99
|
|
|
NITROGLYCERIN 0.3 MG 7.5MG/1EA
|
Facility
|
OP
|
$124.99
|
|
|
Service Code
|
NDC 50742051530
|
| Hospital Charge Code |
25001087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$119.99 |
| Rate for Payer: Aetna Commercial |
$96.24
|
| Rate for Payer: Anthem Medicaid |
$42.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.49
|
| Rate for Payer: Cash Price |
$62.49
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: First Health Commercial |
$118.74
|
| Rate for Payer: Humana Commercial |
$106.24
|
| Rate for Payer: Humana KY Medicaid |
$42.98
|
| Rate for Payer: Kentucky WC Medicaid |
$43.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.99
|
| Rate for Payer: Ohio Health Group HMO |
$93.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.75
|
| Rate for Payer: PHCS Commercial |
$119.99
|
| Rate for Payer: United Healthcare All Payer |
$109.99
|
|
|
NITROGLYCERIN 0.4 MG/ 10MG/1EA
|
Facility
|
OP
|
$5.02
|
|
|
Service Code
|
NDC 378911293
|
| Hospital Charge Code |
25001088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.77
|
| Rate for Payer: Humana Commercial |
$4.27
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.42
|
| Rate for Payer: Ohio Health Group HMO |
$3.76
|
| 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 |
$1.56
|
| Rate for Payer: PHCS Commercial |
$4.82
|
| Rate for Payer: United Healthcare All Payer |
$4.42
|
| Rate for Payer: Aetna Commercial |
$3.87
|
|
|
NITROGLYCERIN 0.4 MG/ 10MG/1EA
|
Facility
|
IP
|
$5.02
|
|
|
Service Code
|
NDC 378911293
|
| Hospital Charge Code |
25001088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.77
|
| Rate for Payer: Humana Commercial |
$4.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.42
|
| Rate for Payer: Ohio Health Group HMO |
$3.76
|
| 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 |
$1.56
|
| Rate for Payer: PHCS Commercial |
$4.82
|
| Rate for Payer: United Healthcare All Payer |
$4.42
|
|
|
NITROGLYCERIN 0.4MG 10ML SYR
|
Facility
|
OP
|
$63.35
|
|
|
Service Code
|
NDC 517481001
|
| Hospital Charge Code |
25003281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$60.82 |
| Rate for Payer: Aetna Commercial |
$48.78
|
| Rate for Payer: Anthem Medicaid |
$21.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.41
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cigna Commercial |
$52.58
|
| Rate for Payer: First Health Commercial |
$60.18
|
| Rate for Payer: Humana Commercial |
$53.85
|
| Rate for Payer: Humana KY Medicaid |
$21.79
|
| Rate for Payer: Kentucky WC Medicaid |
$22.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.75
|
| Rate for Payer: Ohio Health Group HMO |
$47.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.64
|
| Rate for Payer: PHCS Commercial |
$60.82
|
| Rate for Payer: United Healthcare All Payer |
$55.75
|
|
|
NITROGLYCERIN 0.4MG 10ML SYR
|
Facility
|
IP
|
$63.35
|
|
|
Service Code
|
NDC 517481001
|
| Hospital Charge Code |
25003281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$60.82 |
| Rate for Payer: Aetna Commercial |
$48.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.41
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cigna Commercial |
$52.58
|
| Rate for Payer: First Health Commercial |
$60.18
|
| Rate for Payer: Humana Commercial |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.75
|
| Rate for Payer: Ohio Health Group HMO |
$47.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.64
|
| Rate for Payer: PHCS Commercial |
$60.82
|
| Rate for Payer: United Healthcare All Payer |
$55.75
|
|
|
NITROGLYCERIN 0.4MG 10ML SYR
|
Facility
|
IP
|
$60.35
|
|
| Hospital Charge Code |
25003281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$57.94 |
| Rate for Payer: Aetna Commercial |
$46.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.07
|
| Rate for Payer: Cash Price |
$30.18
|
| Rate for Payer: Cigna Commercial |
$50.09
|
| Rate for Payer: First Health Commercial |
$57.33
|
| Rate for Payer: Humana Commercial |
$51.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.11
|
| Rate for Payer: Ohio Health Group HMO |
$45.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$57.94
|
| Rate for Payer: United Healthcare All Payer |
$53.11
|
|
|
NITROGLYCERIN 0.4MG 10ML SYR
|
Facility
|
OP
|
$60.35
|
|
| Hospital Charge Code |
25003281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$57.94 |
| Rate for Payer: Humana Commercial |
$51.30
|
| Rate for Payer: Humana KY Medicaid |
$20.75
|
| Rate for Payer: Kentucky WC Medicaid |
$20.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.11
|
| Rate for Payer: Ohio Health Group HMO |
$45.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$57.94
|
| Rate for Payer: United Healthcare All Payer |
$53.11
|
| Rate for Payer: Aetna Commercial |
$46.47
|
| Rate for Payer: Anthem Medicaid |
$20.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.07
|
| Rate for Payer: Cash Price |
$30.18
|
| Rate for Payer: Cigna Commercial |
$50.09
|
| Rate for Payer: First Health Commercial |
$57.33
|
|
|
NITROGLYCERIN 0.4 MG SL T (3/B
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
NITROGLYCERIN 0.4 MG SL T (3/B
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
