|
NITROSTAT (NITROGLYCERI 100TAB
|
Facility
|
OP
|
$3.09
|
|
|
Service Code
|
NDC 58151030901
|
| Hospital Charge Code |
25003291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Anthem Medicaid |
$1.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.41
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Cigna Commercial |
$2.56
|
| Rate for Payer: First Health Commercial |
$2.94
|
| Rate for Payer: Humana Commercial |
$2.63
|
| Rate for Payer: Humana KY Medicaid |
$1.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.72
|
| Rate for Payer: Ohio Health Group HMO |
$2.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.13
|
| Rate for Payer: PHCS Commercial |
$2.97
|
| Rate for Payer: United Healthcare All Payer |
$2.72
|
|
|
NIVESTYM 1MCG(300MCG)SDV
|
Facility
|
OP
|
$1,193.55
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
25004543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1,145.81 |
| Rate for Payer: Aetna Commercial |
$919.03
|
| Rate for Payer: Anthem Medicaid |
$410.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$930.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$596.78
|
| Rate for Payer: Cash Price |
$596.78
|
| Rate for Payer: Cigna Commercial |
$990.65
|
| Rate for Payer: First Health Commercial |
$1,133.87
|
| Rate for Payer: Humana Commercial |
$1,014.52
|
| Rate for Payer: Humana KY Medicaid |
$410.46
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Kentucky WC Medicaid |
$414.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$978.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$880.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$418.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,050.32
|
| Rate for Payer: Ohio Health Group HMO |
$895.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$954.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,038.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$823.55
|
| Rate for Payer: PHCS Commercial |
$1,145.81
|
| Rate for Payer: United Healthcare All Payer |
$1,050.32
|
|
|
NIVESTYM 1MCG(300MCG)SDV
|
Facility
|
IP
|
$1,193.55
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
25004543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$358.06 |
| Max. Negotiated Rate |
$1,145.81 |
| Rate for Payer: Aetna Commercial |
$919.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$930.97
|
| Rate for Payer: Cash Price |
$596.78
|
| Rate for Payer: Cigna Commercial |
$990.65
|
| Rate for Payer: First Health Commercial |
$1,133.87
|
| Rate for Payer: Humana Commercial |
$1,014.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$978.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$880.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$358.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,050.32
|
| Rate for Payer: Ohio Health Group HMO |
$895.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$954.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,038.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$823.55
|
| Rate for Payer: PHCS Commercial |
$1,145.81
|
| Rate for Payer: United Healthcare All Payer |
$1,050.32
|
|
|
NIVESTYM (1mcg)480MCG/0.8ML
|
Facility
|
OP
|
$1,909.68
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
25002735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1,833.29 |
| Rate for Payer: Aetna Commercial |
$1,470.45
|
| Rate for Payer: Anthem Medicaid |
$656.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$954.84
|
| Rate for Payer: Cash Price |
$954.84
|
| Rate for Payer: Cigna Commercial |
$1,585.03
|
| Rate for Payer: First Health Commercial |
$1,814.20
|
| Rate for Payer: Humana Commercial |
$1,623.23
|
| Rate for Payer: Humana KY Medicaid |
$656.74
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Kentucky WC Medicaid |
$663.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,565.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$669.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,527.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,661.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,317.68
|
| Rate for Payer: PHCS Commercial |
$1,833.29
|
| Rate for Payer: United Healthcare All Payer |
$1,680.52
|
|
|
NIVESTYM (1mcg)480MCG/0.8ML
|
Facility
|
IP
|
$1,909.68
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
25002735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$572.90 |
| Max. Negotiated Rate |
$1,833.29 |
| Rate for Payer: Aetna Commercial |
$1,470.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.55
|
| Rate for Payer: Cash Price |
$954.84
|
| Rate for Payer: Cigna Commercial |
$1,585.03
|
| Rate for Payer: First Health Commercial |
$1,814.20
|
| Rate for Payer: Humana Commercial |
$1,623.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,565.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$572.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,527.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,661.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,317.68
|
| Rate for Payer: PHCS Commercial |
$1,833.29
|
| Rate for Payer: United Healthcare All Payer |
$1,680.52
|
|
|
NIVESTYM 300MCG/0.5ML SYRINGE
|
Facility
|
IP
|
$1,193.55
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
25002734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$358.06 |
| Max. Negotiated Rate |
$1,145.81 |
| Rate for Payer: Aetna Commercial |
$919.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$930.97
|
| Rate for Payer: Cash Price |
$596.78
|
| Rate for Payer: Cigna Commercial |
$990.65
|
| Rate for Payer: First Health Commercial |
$1,133.87
|
| Rate for Payer: Humana Commercial |
$1,014.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$978.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$880.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$358.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,050.32
|
| Rate for Payer: Ohio Health Group HMO |
$895.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$954.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,038.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$823.55
|
| Rate for Payer: PHCS Commercial |
$1,145.81
|
| Rate for Payer: United Healthcare All Payer |
$1,050.32
|
|
|
NIVESTYM 300MCG/0.5ML SYRINGE
|
Facility
|
OP
|
$1,193.55
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
25002734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1,145.81 |
| Rate for Payer: Aetna Commercial |
$919.03
|
| Rate for Payer: Anthem Medicaid |
$410.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$930.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$596.78
|
| Rate for Payer: Cash Price |
$596.78
|
| Rate for Payer: Cigna Commercial |
$990.65
|
| Rate for Payer: First Health Commercial |
$1,133.87
|
| Rate for Payer: Humana Commercial |
$1,014.52
|
| Rate for Payer: Humana KY Medicaid |
$410.46
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Kentucky WC Medicaid |
$414.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$978.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$880.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$418.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,050.32
|
| Rate for Payer: Ohio Health Group HMO |
$895.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$954.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,038.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$823.55
|
| Rate for Payer: PHCS Commercial |
$1,145.81
|
| Rate for Payer: United Healthcare All Payer |
$1,050.32
|
|
|
NIVOLUMAB 100MG/10ML
|
Facility
|
IP
|
$17,683.67
|
|
|
Service Code
|
HCPCS J9299
|
| Hospital Charge Code |
25002664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,305.10 |
| Max. Negotiated Rate |
$16,976.32 |
| Rate for Payer: Aetna Commercial |
$13,616.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,793.26
|
| Rate for Payer: Cash Price |
$8,841.83
|
| Rate for Payer: Cigna Commercial |
$14,677.45
|
| Rate for Payer: First Health Commercial |
$16,799.49
|
| Rate for Payer: Humana Commercial |
$15,031.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,500.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,050.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,305.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,561.63
|
| Rate for Payer: Ohio Health Group HMO |
$13,262.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,146.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,384.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,201.73
|
| Rate for Payer: PHCS Commercial |
$16,976.32
|
| Rate for Payer: United Healthcare All Payer |
$15,561.63
|
|
|
NIVOLUMAB 100MG/10ML
|
Facility
|
OP
|
$17,683.67
|
|
|
Service Code
|
HCPCS J9299
|
| Hospital Charge Code |
25002664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$16,976.32 |
| Rate for Payer: Aetna Commercial |
$13,616.43
|
| Rate for Payer: Anthem Medicaid |
$6,081.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$33.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,793.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$46.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.55
|
| Rate for Payer: Cash Price |
$8,841.83
|
| Rate for Payer: Cash Price |
$8,841.83
|
| Rate for Payer: Cigna Commercial |
$14,677.45
|
| Rate for Payer: First Health Commercial |
$16,799.49
|
| Rate for Payer: Humana Commercial |
$15,031.12
|
| Rate for Payer: Humana KY Medicaid |
$6,081.41
|
| Rate for Payer: Humana Medicare Advantage |
$33.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,143.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,500.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,050.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,203.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,561.63
|
| Rate for Payer: Ohio Health Group HMO |
$13,262.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,146.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,384.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,201.73
|
| Rate for Payer: PHCS Commercial |
$16,976.32
|
| Rate for Payer: United Healthcare All Payer |
$15,561.63
|
|
|
NIX COMP LICE TX KIT COMBO PKG
|
Facility
|
OP
|
$34.94
|
|
|
Service Code
|
NDC 63736024797
|
| Hospital Charge Code |
25001090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$33.54 |
| Rate for Payer: Aetna Commercial |
$26.90
|
| Rate for Payer: Anthem Medicaid |
$12.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.25
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cigna Commercial |
$29.00
|
| Rate for Payer: First Health Commercial |
$33.19
|
| Rate for Payer: Humana Commercial |
$29.70
|
| Rate for Payer: Humana KY Medicaid |
$12.02
|
| Rate for Payer: Kentucky WC Medicaid |
$12.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.75
|
| Rate for Payer: Ohio Health Group HMO |
$26.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.11
|
| Rate for Payer: PHCS Commercial |
$33.54
|
| Rate for Payer: United Healthcare All Payer |
$30.75
|
|
|
NIX COMP LICE TX KIT COMBO PKG
|
Facility
|
IP
|
$34.94
|
|
|
Service Code
|
NDC 63736024797
|
| Hospital Charge Code |
25001090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$33.54 |
| Rate for Payer: Aetna Commercial |
$26.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.25
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cigna Commercial |
$29.00
|
| Rate for Payer: First Health Commercial |
$33.19
|
| Rate for Payer: Humana Commercial |
$29.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.75
|
| Rate for Payer: Ohio Health Group HMO |
$26.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.11
|
| Rate for Payer: PHCS Commercial |
$33.54
|
| Rate for Payer: United Healthcare All Payer |
$30.75
|
|
|
NIX (PERMETHRIN) CREME RIN 2OZ
|
Facility
|
IP
|
$25.22
|
|
|
Service Code
|
NDC 46122010846
|
| Hospital Charge Code |
25001089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$19.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.67
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cigna Commercial |
$20.93
|
| Rate for Payer: First Health Commercial |
$23.96
|
| Rate for Payer: Humana Commercial |
$21.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.19
|
| Rate for Payer: Ohio Health Group HMO |
$18.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.40
|
| Rate for Payer: PHCS Commercial |
$24.21
|
| Rate for Payer: United Healthcare All Payer |
$22.19
|
|
|
NIX (PERMETHRIN) CREME RIN 2OZ
|
Facility
|
OP
|
$25.22
|
|
|
Service Code
|
NDC 46122010846
|
| Hospital Charge Code |
25001089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$19.42
|
| Rate for Payer: Anthem Medicaid |
$8.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.67
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cigna Commercial |
$20.93
|
| Rate for Payer: First Health Commercial |
$23.96
|
| Rate for Payer: Humana Commercial |
$21.44
|
| Rate for Payer: Humana KY Medicaid |
$8.67
|
| Rate for Payer: Kentucky WC Medicaid |
$8.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.19
|
| Rate for Payer: Ohio Health Group HMO |
$18.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.40
|
| Rate for Payer: PHCS Commercial |
$24.21
|
| Rate for Payer: United Healthcare All Payer |
$22.19
|
|
|
NIZORAL (KETOCONAZO 200MG/1TAB
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 35573043330
|
| Hospital Charge Code |
25001091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
NIZORAL (KETOCONAZO 200MG/1TAB
|
Facility
|
OP
|
$9.05
|
|
|
Service Code
|
NDC 35573043330
|
| Hospital Charge Code |
25001091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
NIZORAL(KETOCONAZOLE)2% C 30GM
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
NDC 168009930
|
| Hospital Charge Code |
25001092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.60
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: First Health Commercial |
$3.16
|
| Rate for Payer: Humana Commercial |
$2.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.93
|
| Rate for Payer: Ohio Health Group HMO |
$2.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.30
|
| Rate for Payer: PHCS Commercial |
$3.20
|
| Rate for Payer: United Healthcare All Payer |
$2.93
|
|
|
NIZORAL(KETOCONAZOLE)2% C 30GM
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
NDC 168009930
|
| Hospital Charge Code |
25001092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna Commercial |
$2.56
|
| Rate for Payer: Anthem Medicaid |
$1.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.60
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: First Health Commercial |
$3.16
|
| Rate for Payer: Humana Commercial |
$2.83
|
| Rate for Payer: Humana KY Medicaid |
$1.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.93
|
| Rate for Payer: Ohio Health Group HMO |
$2.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.30
|
| Rate for Payer: PHCS Commercial |
$3.20
|
| Rate for Payer: United Healthcare All Payer |
$2.93
|
|
|
NIZORAL(KETOCONAZOLE)2% SH 4OZ
|
Facility
|
IP
|
$9.47
|
|
|
Service Code
|
NDC 63646001004
|
| Hospital Charge Code |
25001093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$7.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.39
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.86
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: Humana Commercial |
$8.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.53
|
| Rate for Payer: PHCS Commercial |
$9.09
|
| Rate for Payer: United Healthcare All Payer |
$8.33
|
|
|
NIZORAL(KETOCONAZOLE)2% SH 4OZ
|
Facility
|
OP
|
$9.47
|
|
|
Service Code
|
NDC 63646001004
|
| Hospital Charge Code |
25001093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$7.29
|
| Rate for Payer: Anthem Medicaid |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.39
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.86
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: Humana Commercial |
$8.05
|
| Rate for Payer: Humana KY Medicaid |
$3.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.33
|
| Rate for Payer: Ohio Health Group HMO |
$7.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.53
|
| Rate for Payer: PHCS Commercial |
$9.09
|
| Rate for Payer: United Healthcare All Payer |
$8.33
|
|
|
NJX AA&/STRD AX NERVE IMG
|
Professional
|
Both
|
$2,085.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
76102829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$1,251.00 |
| Rate for Payer: Aetna Commercial |
$119.06
|
| Rate for Payer: Ambetter Exchange |
$61.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$104.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$61.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$61.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.39
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$113.07
|
| Rate for Payer: Healthspan PPO |
$158.41
|
| Rate for Payer: Humana Medicaid |
$104.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$61.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.01
|
| Rate for Payer: Molina Healthcare Passport |
$104.91
|
| Rate for Payer: Multiplan PHCS |
$1,251.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$79.51
|
| Rate for Payer: UHCCP Medicaid |
$32.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$105.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$61.16
|
|
|
NJX AA&/STRD AX NERVE IMG
|
Facility
|
OP
|
$2,085.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
76102829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$717.03 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem Medicaid |
$717.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Humana KY Medicaid |
$717.03
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$724.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$731.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,813.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,438.65
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
NJX AA&/STRD AX NERVE IMG
|
Facility
|
IP
|
$2,085.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
76102829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$625.50 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,813.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,438.65
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
NJX AA&/STRD AX NERVE IMG(P
|
Professional
|
Both
|
$180.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
761P2829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$158.41 |
| Rate for Payer: Aetna Commercial |
$119.06
|
| Rate for Payer: Ambetter Exchange |
$61.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$104.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$61.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$61.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.39
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$113.07
|
| Rate for Payer: Healthspan PPO |
$158.41
|
| Rate for Payer: Humana Medicaid |
$104.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$61.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.01
|
| Rate for Payer: Molina Healthcare Passport |
$104.91
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$79.51
|
| Rate for Payer: UHCCP Medicaid |
$32.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$105.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$61.16
|
|
|
NJX AA&/STRD AX NERVE IMG(T
|
Facility
|
OP
|
$1,905.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
761T2829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,828.80 |
| Rate for Payer: Aetna Commercial |
$1,466.85
|
| Rate for Payer: Anthem Medicaid |
$655.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$952.50
|
| Rate for Payer: Cash Price |
$952.50
|
| Rate for Payer: Cigna Commercial |
$1,581.15
|
| Rate for Payer: First Health Commercial |
$1,809.75
|
| Rate for Payer: Humana Commercial |
$1,619.25
|
| Rate for Payer: Humana KY Medicaid |
$655.13
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$661.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,562.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,676.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,524.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,657.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,314.45
|
| Rate for Payer: PHCS Commercial |
$1,828.80
|
| Rate for Payer: United Healthcare All Payer |
$1,676.40
|
|
|
NJX AA&/STRD AX NERVE IMG(T
|
Facility
|
IP
|
$1,905.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
761T2829
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$571.50 |
| Max. Negotiated Rate |
$1,828.80 |
| Rate for Payer: Aetna Commercial |
$1,466.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.90
|
| Rate for Payer: Cash Price |
$952.50
|
| Rate for Payer: Cigna Commercial |
$1,581.15
|
| Rate for Payer: First Health Commercial |
$1,809.75
|
| Rate for Payer: Humana Commercial |
$1,619.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,562.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,676.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,524.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,657.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,314.45
|
| Rate for Payer: PHCS Commercial |
$1,828.80
|
| Rate for Payer: United Healthcare All Payer |
$1,676.40
|
|
