|
OXYBUTYNIN XL 10 MG TAB.ER.24
|
Facility
|
IP
|
$4.94
|
|
|
Service Code
|
NDC 62175027137
|
| Hospital Charge Code |
25003955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna Commercial |
$4.10
|
| Rate for Payer: First Health Commercial |
$4.69
|
| Rate for Payer: Humana Commercial |
$4.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.35
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$4.74
|
| Rate for Payer: United Healthcare All Payer |
$4.35
|
|
|
OXYBUTYNIN XL 15 MG TAB.ER.24
|
Facility
|
OP
|
$4.96
|
|
|
Service Code
|
NDC 62175027237
|
| Hospital Charge Code |
25003956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.76 |
| Rate for Payer: Aetna Commercial |
$3.82
|
| Rate for Payer: Anthem Medicaid |
$1.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.87
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.12
|
| Rate for Payer: First Health Commercial |
$4.71
|
| Rate for Payer: Humana Commercial |
$4.22
|
| Rate for Payer: Humana KY Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.76
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
OXYBUTYNIN XL 15 MG TAB.ER.24
|
Facility
|
IP
|
$4.96
|
|
|
Service Code
|
NDC 62175027237
|
| Hospital Charge Code |
25003956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.76 |
| Rate for Payer: Aetna Commercial |
$3.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.87
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.12
|
| Rate for Payer: First Health Commercial |
$4.71
|
| Rate for Payer: Humana Commercial |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.76
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
OXYCODONE10MG/0.5MLORSYR(0.5ML
|
Facility
|
OP
|
$62.33
|
|
|
Service Code
|
NDC 71930002330
|
| Hospital Charge Code |
25003332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$59.84 |
| Rate for Payer: Aetna Commercial |
$47.99
|
| Rate for Payer: Anthem Medicaid |
$21.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.62
|
| Rate for Payer: Cash Price |
$31.16
|
| Rate for Payer: Cigna Commercial |
$51.73
|
| Rate for Payer: First Health Commercial |
$59.21
|
| Rate for Payer: Humana Commercial |
$52.98
|
| Rate for Payer: Humana KY Medicaid |
$21.44
|
| Rate for Payer: Kentucky WC Medicaid |
$21.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.85
|
| Rate for Payer: Ohio Health Group HMO |
$46.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.01
|
| Rate for Payer: PHCS Commercial |
$59.84
|
| Rate for Payer: United Healthcare All Payer |
$54.85
|
|
|
OXYCODONE10MG/0.5MLORSYR(0.5ML
|
Facility
|
IP
|
$62.33
|
|
|
Service Code
|
NDC 71930002330
|
| Hospital Charge Code |
25003332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$59.84 |
| Rate for Payer: Aetna Commercial |
$47.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.62
|
| Rate for Payer: Cash Price |
$31.16
|
| Rate for Payer: Cigna Commercial |
$51.73
|
| Rate for Payer: First Health Commercial |
$59.21
|
| Rate for Payer: Humana Commercial |
$52.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.85
|
| Rate for Payer: Ohio Health Group HMO |
$46.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.01
|
| Rate for Payer: PHCS Commercial |
$59.84
|
| Rate for Payer: United Healthcare All Payer |
$54.85
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$60.20
|
|
|
Service Code
|
NDC 406055201
|
| Hospital Charge Code |
25001149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$57.79 |
| Rate for Payer: Aetna Commercial |
$46.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.96
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: Cigna Commercial |
$49.97
|
| Rate for Payer: First Health Commercial |
$57.19
|
| Rate for Payer: Humana Commercial |
$51.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.98
|
| Rate for Payer: Ohio Health Group HMO |
$45.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.54
|
| Rate for Payer: PHCS Commercial |
$57.79
|
| Rate for Payer: United Healthcare All Payer |
$52.98
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$60.20
|
|
|
Service Code
|
NDC 406055201
|
| Hospital Charge Code |
25001149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$57.79 |
| Rate for Payer: Aetna Commercial |
$46.35
|
| Rate for Payer: Anthem Medicaid |
$20.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.96
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: Cigna Commercial |
$49.97
|
| Rate for Payer: First Health Commercial |
$57.19
|
| Rate for Payer: Humana Commercial |
$51.17
|
| Rate for Payer: Humana KY Medicaid |
$20.70
|
| Rate for Payer: Kentucky WC Medicaid |
$20.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.98
|
| Rate for Payer: Ohio Health Group HMO |
$45.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.54
|
| Rate for Payer: PHCS Commercial |
$57.79
|
| Rate for Payer: United Healthcare All Payer |
$52.98
|
|
|
OXYCODONE I R 30MG TAB
|
Facility
|
OP
|
$60.49
|
|
|
Service Code
|
NDC 406853001
|
| Hospital Charge Code |
25001150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.15 |
| Max. Negotiated Rate |
$58.07 |
| Rate for Payer: Aetna Commercial |
$46.58
|
| Rate for Payer: Anthem Medicaid |
$20.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.18
|
| Rate for Payer: Cash Price |
$30.25
|
| Rate for Payer: Cigna Commercial |
$50.21
|
| Rate for Payer: First Health Commercial |
$57.47
|
| Rate for Payer: Humana Commercial |
$51.42
|
| Rate for Payer: Humana KY Medicaid |
$20.80
|
| Rate for Payer: Kentucky WC Medicaid |
$21.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.23
|
| Rate for Payer: Ohio Health Group HMO |
$45.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.74
|
| Rate for Payer: PHCS Commercial |
$58.07
|
| Rate for Payer: United Healthcare All Payer |
$53.23
|
|
|
OXYCODONE I R 30MG TAB
|
Facility
|
IP
|
$60.49
|
|
|
Service Code
|
NDC 406853001
|
| Hospital Charge Code |
25001150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.15 |
| Max. Negotiated Rate |
$58.07 |
| Rate for Payer: Aetna Commercial |
$46.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.18
|
| Rate for Payer: Cash Price |
$30.25
|
| Rate for Payer: Cigna Commercial |
$50.21
|
| Rate for Payer: First Health Commercial |
$57.47
|
| Rate for Payer: Humana Commercial |
$51.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.23
|
| Rate for Payer: Ohio Health Group HMO |
$45.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.74
|
| Rate for Payer: PHCS Commercial |
$58.07
|
| Rate for Payer: United Healthcare All Payer |
$53.23
|
|
|
OXYCONTIN 15MG TABLET
|
Facility
|
IP
|
$68.34
|
|
|
Service Code
|
NDC 59011041510
|
| Hospital Charge Code |
25001152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.50 |
| Max. Negotiated Rate |
$65.61 |
| Rate for Payer: Aetna Commercial |
$52.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.31
|
| Rate for Payer: Cash Price |
$34.17
|
| Rate for Payer: Cigna Commercial |
$56.72
|
| Rate for Payer: First Health Commercial |
$64.92
|
| Rate for Payer: Humana Commercial |
$58.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.14
|
| Rate for Payer: Ohio Health Group HMO |
$51.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.15
|
| Rate for Payer: PHCS Commercial |
$65.61
|
| Rate for Payer: United Healthcare All Payer |
$60.14
|
|
|
OXYCONTIN 15MG TABLET
|
Facility
|
OP
|
$68.34
|
|
|
Service Code
|
NDC 59011041510
|
| Hospital Charge Code |
25001152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.50 |
| Max. Negotiated Rate |
$65.61 |
| Rate for Payer: Aetna Commercial |
$52.62
|
| Rate for Payer: Anthem Medicaid |
$23.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.31
|
| Rate for Payer: Cash Price |
$34.17
|
| Rate for Payer: Cigna Commercial |
$56.72
|
| Rate for Payer: First Health Commercial |
$64.92
|
| Rate for Payer: Humana Commercial |
$58.09
|
| Rate for Payer: Humana KY Medicaid |
$23.50
|
| Rate for Payer: Kentucky WC Medicaid |
$23.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.14
|
| Rate for Payer: Ohio Health Group HMO |
$51.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.15
|
| Rate for Payer: PHCS Commercial |
$65.61
|
| Rate for Payer: United Healthcare All Payer |
$60.14
|
|
|
OXYCONTIN (OXYCODONE 20MG/1TAB
|
Facility
|
IP
|
$70.57
|
|
|
Service Code
|
NDC 59011042010
|
| Hospital Charge Code |
25001151
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.17 |
| Max. Negotiated Rate |
$67.75 |
| Rate for Payer: Aetna Commercial |
$54.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.04
|
| Rate for Payer: Cash Price |
$35.28
|
| Rate for Payer: Cigna Commercial |
$58.57
|
| Rate for Payer: First Health Commercial |
$67.04
|
| Rate for Payer: Humana Commercial |
$59.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.10
|
| Rate for Payer: Ohio Health Group HMO |
$52.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.69
|
| Rate for Payer: PHCS Commercial |
$67.75
|
| Rate for Payer: United Healthcare All Payer |
$62.10
|
|
|
OXYCONTIN (OXYCODONE 20MG/1TAB
|
Facility
|
OP
|
$70.57
|
|
|
Service Code
|
NDC 59011042010
|
| Hospital Charge Code |
25001151
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.17 |
| Max. Negotiated Rate |
$67.75 |
| Rate for Payer: Aetna Commercial |
$54.34
|
| Rate for Payer: Anthem Medicaid |
$24.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.04
|
| Rate for Payer: Cash Price |
$35.28
|
| Rate for Payer: Cigna Commercial |
$58.57
|
| Rate for Payer: First Health Commercial |
$67.04
|
| Rate for Payer: Humana Commercial |
$59.98
|
| Rate for Payer: Humana KY Medicaid |
$24.27
|
| Rate for Payer: Kentucky WC Medicaid |
$24.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.10
|
| Rate for Payer: Ohio Health Group HMO |
$52.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.69
|
| Rate for Payer: PHCS Commercial |
$67.75
|
| Rate for Payer: United Healthcare All Payer |
$62.10
|
|
|
OXYMETAZOLINE 0.05% 30mL
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 45802041059
|
| Hospital Charge Code |
25004157
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
OXYMETAZOLINE 0.05% 30mL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 45802041059
|
| Hospital Charge Code |
25004157
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
OXYMORPHONE 5MG TABLET
|
Facility
|
IP
|
$61.68
|
|
|
Service Code
|
NDC 10702007006
|
| Hospital Charge Code |
25004250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.50 |
| Max. Negotiated Rate |
$59.21 |
| Rate for Payer: Aetna Commercial |
$47.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.11
|
| Rate for Payer: Cash Price |
$30.84
|
| Rate for Payer: Cigna Commercial |
$51.19
|
| Rate for Payer: First Health Commercial |
$58.60
|
| Rate for Payer: Humana Commercial |
$52.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.28
|
| Rate for Payer: Ohio Health Group HMO |
$46.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.56
|
| Rate for Payer: PHCS Commercial |
$59.21
|
| Rate for Payer: United Healthcare All Payer |
$54.28
|
|
|
OXYMORPHONE 5MG TABLET
|
Facility
|
OP
|
$61.68
|
|
|
Service Code
|
NDC 10702007006
|
| Hospital Charge Code |
25004250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.50 |
| Max. Negotiated Rate |
$59.21 |
| Rate for Payer: Aetna Commercial |
$47.49
|
| Rate for Payer: Anthem Medicaid |
$21.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.11
|
| Rate for Payer: Cash Price |
$30.84
|
| Rate for Payer: Cigna Commercial |
$51.19
|
| Rate for Payer: First Health Commercial |
$58.60
|
| Rate for Payer: Humana Commercial |
$52.43
|
| Rate for Payer: Humana KY Medicaid |
$21.21
|
| Rate for Payer: Kentucky WC Medicaid |
$21.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.28
|
| Rate for Payer: Ohio Health Group HMO |
$46.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.56
|
| Rate for Payer: PHCS Commercial |
$59.21
|
| Rate for Payer: United Healthcare All Payer |
$54.28
|
|
|
OXYMORPHONE ER 5MG TABLET
|
Facility
|
IP
|
$65.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$62.66 |
| Rate for Payer: Aetna Commercial |
$50.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.91
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cigna Commercial |
$54.17
|
| Rate for Payer: First Health Commercial |
$62.01
|
| Rate for Payer: Humana Commercial |
$55.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.44
|
| Rate for Payer: Ohio Health Group HMO |
$48.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.04
|
| Rate for Payer: PHCS Commercial |
$62.66
|
| Rate for Payer: United Healthcare All Payer |
$57.44
|
|
|
OXYMORPHONE ER 5MG TABLET
|
Facility
|
OP
|
$65.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004251
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$62.66 |
| Rate for Payer: Aetna Commercial |
$50.26
|
| Rate for Payer: Anthem Medicaid |
$22.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.91
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cigna Commercial |
$54.17
|
| Rate for Payer: First Health Commercial |
$62.01
|
| Rate for Payer: Humana Commercial |
$55.48
|
| Rate for Payer: Humana KY Medicaid |
$22.45
|
| Rate for Payer: Kentucky WC Medicaid |
$22.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.44
|
| Rate for Payer: Ohio Health Group HMO |
$48.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.04
|
| Rate for Payer: PHCS Commercial |
$62.66
|
| Rate for Payer: United Healthcare All Payer |
$57.44
|
|
|
OXYTOCIN CHALLENGE TEST
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
92000003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$114.30 |
| Max. Negotiated Rate |
$365.76 |
| Rate for Payer: Aetna Commercial |
$293.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.18
|
| Rate for Payer: Cash Price |
$190.50
|
| Rate for Payer: Cigna Commercial |
$316.23
|
| Rate for Payer: First Health Commercial |
$361.95
|
| Rate for Payer: Humana Commercial |
$323.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$312.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$335.28
|
| Rate for Payer: Ohio Health Group HMO |
$285.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$331.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.89
|
| Rate for Payer: PHCS Commercial |
$365.76
|
| Rate for Payer: United Healthcare All Payer |
$335.28
|
|
|
OXYTOCIN CHALLENGE TEST
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
92000003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$131.03 |
| Max. Negotiated Rate |
$365.76 |
| Rate for Payer: Aetna Commercial |
$293.37
|
| Rate for Payer: Anthem Medicaid |
$131.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$185.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$260.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$250.94
|
| Rate for Payer: Cash Price |
$190.50
|
| Rate for Payer: Cash Price |
$190.50
|
| Rate for Payer: Cigna Commercial |
$316.23
|
| Rate for Payer: First Health Commercial |
$361.95
|
| Rate for Payer: Humana Commercial |
$323.85
|
| Rate for Payer: Humana KY Medicaid |
$131.03
|
| Rate for Payer: Humana Medicare Advantage |
$185.88
|
| Rate for Payer: Kentucky WC Medicaid |
$132.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$312.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$223.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$133.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$335.28
|
| Rate for Payer: Ohio Health Group HMO |
$285.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$331.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.89
|
| Rate for Payer: PHCS Commercial |
$365.76
|
| Rate for Payer: United Healthcare All Payer |
$335.28
|
|
|
OXYTROL 3.9 MG 24 HR PATCH
|
Facility
|
IP
|
$156.98
|
|
|
Service Code
|
NDC 23615308
|
| Hospital Charge Code |
25001153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.09 |
| Max. Negotiated Rate |
$150.70 |
| Rate for Payer: Aetna Commercial |
$120.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$122.44
|
| Rate for Payer: Cash Price |
$78.49
|
| Rate for Payer: Cigna Commercial |
$130.29
|
| Rate for Payer: First Health Commercial |
$149.13
|
| Rate for Payer: Humana Commercial |
$133.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$128.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$138.14
|
| Rate for Payer: Ohio Health Group HMO |
$117.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.32
|
| Rate for Payer: PHCS Commercial |
$150.70
|
| Rate for Payer: United Healthcare All Payer |
$138.14
|
|
|
OXYTROL 3.9 MG 24 HR PATCH
|
Facility
|
OP
|
$156.98
|
|
|
Service Code
|
NDC 23615308
|
| Hospital Charge Code |
25001153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.09 |
| Max. Negotiated Rate |
$150.70 |
| Rate for Payer: Aetna Commercial |
$120.87
|
| Rate for Payer: Anthem Medicaid |
$53.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$122.44
|
| Rate for Payer: Cash Price |
$78.49
|
| Rate for Payer: Cigna Commercial |
$130.29
|
| Rate for Payer: First Health Commercial |
$149.13
|
| Rate for Payer: Humana Commercial |
$133.43
|
| Rate for Payer: Humana KY Medicaid |
$53.99
|
| Rate for Payer: Kentucky WC Medicaid |
$54.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$128.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$138.14
|
| Rate for Payer: Ohio Health Group HMO |
$117.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.32
|
| Rate for Payer: PHCS Commercial |
$150.70
|
| Rate for Payer: United Healthcare All Payer |
$138.14
|
|
|
PACEMAKER ACCENT DR PM2110
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PACEMAKER ACCENT DR PM2110
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
27000087
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
