|
TEVETEN 600MG TABLET
|
Facility
|
OP
|
$10.74
|
|
|
Service Code
|
NDC 378662993
|
| Hospital Charge Code |
25001516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Aetna Commercial |
$8.27
|
| Rate for Payer: Anthem Medicaid |
$3.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cigna Commercial |
$8.91
|
| Rate for Payer: First Health Commercial |
$10.20
|
| Rate for Payer: Humana Commercial |
$9.13
|
| Rate for Payer: Humana KY Medicaid |
$3.69
|
| Rate for Payer: Kentucky WC Medicaid |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.45
|
| Rate for Payer: Ohio Health Group HMO |
$8.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$10.31
|
| Rate for Payer: United Healthcare All Payer |
$9.45
|
|
|
TEVETEN 600MG TABLET
|
Facility
|
IP
|
$10.74
|
|
|
Service Code
|
NDC 378662993
|
| Hospital Charge Code |
25001516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Aetna Commercial |
$8.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cigna Commercial |
$8.91
|
| Rate for Payer: First Health Commercial |
$10.20
|
| Rate for Payer: Humana Commercial |
$9.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.45
|
| Rate for Payer: Ohio Health Group HMO |
$8.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$10.31
|
| Rate for Payer: United Healthcare All Payer |
$9.45
|
|
|
TEXAS CATHETER MED INTERCON
|
Facility
|
IP
|
$26.47
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.94 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.65
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cigna Commercial |
$21.97
|
| Rate for Payer: First Health Commercial |
$25.15
|
| Rate for Payer: Humana Commercial |
$22.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.29
|
| Rate for Payer: Ohio Health Group HMO |
$19.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.26
|
| Rate for Payer: PHCS Commercial |
$25.41
|
| Rate for Payer: United Healthcare All Payer |
$23.29
|
|
|
TEXAS CATHETER MED INTERCON
|
Facility
|
OP
|
$26.47
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.94 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Anthem Medicaid |
$9.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.65
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cigna Commercial |
$21.97
|
| Rate for Payer: First Health Commercial |
$25.15
|
| Rate for Payer: Humana Commercial |
$22.50
|
| Rate for Payer: Humana KY Medicaid |
$9.10
|
| Rate for Payer: Kentucky WC Medicaid |
$9.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.29
|
| Rate for Payer: Ohio Health Group HMO |
$19.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.26
|
| Rate for Payer: PHCS Commercial |
$25.41
|
| Rate for Payer: United Healthcare All Payer |
$23.29
|
|
|
TEZSPIRE 210MG PFS
|
Facility
|
OP
|
$23,810.83
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,143.25 |
| Max. Negotiated Rate |
$22,858.40 |
| Rate for Payer: Aetna Commercial |
$18,334.34
|
| Rate for Payer: Anthem Medicaid |
$8,188.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,572.45
|
| Rate for Payer: Cash Price |
$11,905.42
|
| Rate for Payer: Cigna Commercial |
$19,762.99
|
| Rate for Payer: First Health Commercial |
$22,620.29
|
| Rate for Payer: Humana Commercial |
$20,239.21
|
| Rate for Payer: Humana KY Medicaid |
$8,188.54
|
| Rate for Payer: Kentucky WC Medicaid |
$8,271.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,524.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,572.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,143.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,352.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,953.53
|
| Rate for Payer: Ohio Health Group HMO |
$17,858.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,048.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,715.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,429.47
|
| Rate for Payer: PHCS Commercial |
$22,858.40
|
| Rate for Payer: United Healthcare All Payer |
$20,953.53
|
|
|
TEZSPIRE 210MG PFS
|
Facility
|
IP
|
$23,810.83
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25004246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,143.25 |
| Max. Negotiated Rate |
$22,858.40 |
| Rate for Payer: Aetna Commercial |
$18,334.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,572.45
|
| Rate for Payer: Cash Price |
$11,905.42
|
| Rate for Payer: Cigna Commercial |
$19,762.99
|
| Rate for Payer: First Health Commercial |
$22,620.29
|
| Rate for Payer: Humana Commercial |
$20,239.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,524.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,572.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,143.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,953.53
|
| Rate for Payer: Ohio Health Group HMO |
$17,858.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,048.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,715.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,429.47
|
| Rate for Payer: PHCS Commercial |
$22,858.40
|
| Rate for Payer: United Healthcare All Payer |
$20,953.53
|
|
|
THALLIUM A PER MCI
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
34000049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
THALLIUM A PER MCI
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
34000049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
THALLIUM A PER MCI
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
34000049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
THALLIUM A PER MCI(T
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
340T0049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
THALLIUM A PER MCI(T
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
340T0049
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
TH CRISIS MANAGEMENT
|
Professional
|
Both
|
$772.00
|
|
|
Service Code
|
HCPCS 90839
|
| Hospital Charge Code |
90000026
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$463.20 |
| Rate for Payer: Aetna Commercial |
$218.31
|
| Rate for Payer: Ambetter Exchange |
$129.02
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$97.31
|
| Rate for Payer: Anthem Medicaid |
$108.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$129.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$129.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.82
|
| Rate for Payer: Cash Price |
$386.00
|
| Rate for Payer: Cash Price |
$386.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$108.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$129.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$110.30
|
| Rate for Payer: Molina Healthcare Passport |
$108.14
|
| Rate for Payer: Multiplan PHCS |
$463.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$167.73
|
| Rate for Payer: UHCCP Medicaid |
$102.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$109.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$129.02
|
|
|
THEO-24 100 MG CAPSULE
|
Facility
|
IP
|
$11.87
|
|
|
Service Code
|
NDC 52244010010
|
| Hospital Charge Code |
25001519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna Commercial |
$9.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.26
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna Commercial |
$9.85
|
| Rate for Payer: First Health Commercial |
$11.28
|
| Rate for Payer: Humana Commercial |
$10.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.45
|
| Rate for Payer: Ohio Health Group HMO |
$8.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.19
|
| Rate for Payer: PHCS Commercial |
$11.40
|
| Rate for Payer: United Healthcare All Payer |
$10.45
|
|
|
THEO-24 100 MG CAPSULE
|
Facility
|
OP
|
$11.87
|
|
|
Service Code
|
NDC 52244010010
|
| Hospital Charge Code |
25001519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna Commercial |
$9.14
|
| Rate for Payer: Anthem Medicaid |
$4.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.26
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cigna Commercial |
$9.85
|
| Rate for Payer: First Health Commercial |
$11.28
|
| Rate for Payer: Humana Commercial |
$10.09
|
| Rate for Payer: Humana KY Medicaid |
$4.08
|
| Rate for Payer: Kentucky WC Medicaid |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.45
|
| Rate for Payer: Ohio Health Group HMO |
$8.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.19
|
| Rate for Payer: PHCS Commercial |
$11.40
|
| Rate for Payer: United Healthcare All Payer |
$10.45
|
|
|
THEO-24 (THEOPHYLLI 200MG/1CAP
|
Facility
|
IP
|
$22.75
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
25001517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$21.84 |
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.75
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$18.88
|
| Rate for Payer: First Health Commercial |
$21.61
|
| Rate for Payer: Humana Commercial |
$19.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.02
|
| Rate for Payer: Ohio Health Group HMO |
$17.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.70
|
| Rate for Payer: PHCS Commercial |
$21.84
|
| Rate for Payer: United Healthcare All Payer |
$20.02
|
|
|
THEO-24 (THEOPHYLLI 200MG/1CAP
|
Facility
|
OP
|
$22.75
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
25001517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$21.84 |
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Anthem Medicaid |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.75
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$18.88
|
| Rate for Payer: First Health Commercial |
$21.61
|
| Rate for Payer: Humana Commercial |
$19.34
|
| Rate for Payer: Humana KY Medicaid |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.02
|
| Rate for Payer: Ohio Health Group HMO |
$17.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.70
|
| Rate for Payer: PHCS Commercial |
$21.84
|
| Rate for Payer: United Healthcare All Payer |
$20.02
|
|
|
THEO-24 (THEOPHYLLI 300MG/1CAP
|
Facility
|
OP
|
$24.07
|
|
|
Service Code
|
NDC 52244030010
|
| Hospital Charge Code |
25001518
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem Medicaid |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Humana KY Medicaid |
$8.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
THEO-24 (THEOPHYLLI 300MG/1CAP
|
Facility
|
IP
|
$24.07
|
|
|
Service Code
|
NDC 52244030010
|
| Hospital Charge Code |
25001518
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
THEO-DUR (THEOPHYLL 300MG/1TAB
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 68462072101
|
| Hospital Charge Code |
25001522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Anthem Medicaid |
$3.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: First Health Commercial |
$8.84
|
| Rate for Payer: Humana Commercial |
$7.91
|
| Rate for Payer: Humana KY Medicaid |
$3.20
|
| Rate for Payer: Kentucky WC Medicaid |
$3.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.42
|
| Rate for Payer: PHCS Commercial |
$8.93
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
THEO-DUR (THEOPHYLL 300MG/1TAB
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 68462072101
|
| Hospital Charge Code |
25001522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: First Health Commercial |
$8.84
|
| Rate for Payer: Humana Commercial |
$7.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.42
|
| Rate for Payer: PHCS Commercial |
$8.93
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
THEO-DUR (THEOPHYLL 450MG/1TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 62332002631
|
| Hospital Charge Code |
25001523
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
THEO-DUR (THEOPHYLL 450MG/1TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 62332002631
|
| Hospital Charge Code |
25001523
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
THEOPHYLLINE 160MG/ 160MG/30ML
|
Facility
|
IP
|
$12.73
|
|
|
Service Code
|
NDC 27808003301
|
| Hospital Charge Code |
25001524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$12.22 |
| Rate for Payer: Aetna Commercial |
$9.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.93
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cigna Commercial |
$10.57
|
| Rate for Payer: First Health Commercial |
$12.09
|
| Rate for Payer: Humana Commercial |
$10.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.20
|
| Rate for Payer: Ohio Health Group HMO |
$9.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.78
|
| Rate for Payer: PHCS Commercial |
$12.22
|
| Rate for Payer: United Healthcare All Payer |
$11.20
|
|
|
THEOPHYLLINE 160MG/ 160MG/30ML
|
Facility
|
OP
|
$12.73
|
|
|
Service Code
|
NDC 27808003301
|
| Hospital Charge Code |
25001524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$12.22 |
| Rate for Payer: Aetna Commercial |
$9.80
|
| Rate for Payer: Anthem Medicaid |
$4.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.93
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cigna Commercial |
$10.57
|
| Rate for Payer: First Health Commercial |
$12.09
|
| Rate for Payer: Humana Commercial |
$10.82
|
| Rate for Payer: Humana KY Medicaid |
$4.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.20
|
| Rate for Payer: Ohio Health Group HMO |
$9.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.78
|
| Rate for Payer: PHCS Commercial |
$12.22
|
| Rate for Payer: United Healthcare All Payer |
$11.20
|
|
|
THERAGRAN (MULTIVITAMIN) 1TAB
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
25001525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
