|
CARDIOVSC PHRM STRESS/ADENOSIN
|
Facility
|
IP
|
$1,166.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200006
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$151.58 |
| Max. Negotiated Rate |
$1,119.36 |
| Rate for Payer: Aetna Commercial |
$897.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$909.48
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$967.78
|
| Rate for Payer: First Health Commercial |
$1,107.70
|
| Rate for Payer: Humana Commercial |
$991.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$860.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$349.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.08
|
| Rate for Payer: Ohio Health Group HMO |
$874.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$361.46
|
| Rate for Payer: PHCS Commercial |
$1,119.36
|
| Rate for Payer: United Healthcare All Payer |
$1,026.08
|
|
|
CARDIOVSC PHRM STRESS/LEXISCAN
|
Facility
|
OP
|
$1,166.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200007
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$151.58 |
| Max. Negotiated Rate |
$1,119.36 |
| Rate for Payer: Aetna Commercial |
$897.82
|
| Rate for Payer: Anthem Medicaid |
$400.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$909.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$967.78
|
| Rate for Payer: First Health Commercial |
$1,107.70
|
| Rate for Payer: Humana Commercial |
$991.10
|
| Rate for Payer: Humana KY Medicaid |
$400.99
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$405.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$860.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$409.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.08
|
| Rate for Payer: Ohio Health Group HMO |
$874.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$361.46
|
| Rate for Payer: PHCS Commercial |
$1,119.36
|
| Rate for Payer: United Healthcare All Payer |
$1,026.08
|
|
|
CARDIOVSC PHRM STRESS/LEXISCAN
|
Facility
|
IP
|
$1,166.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
48200007
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$151.58 |
| Max. Negotiated Rate |
$1,119.36 |
| Rate for Payer: Aetna Commercial |
$897.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$909.48
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$967.78
|
| Rate for Payer: First Health Commercial |
$1,107.70
|
| Rate for Payer: Humana Commercial |
$991.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$860.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$349.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.08
|
| Rate for Payer: Ohio Health Group HMO |
$874.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$361.46
|
| Rate for Payer: PHCS Commercial |
$1,119.36
|
| Rate for Payer: United Healthcare All Payer |
$1,026.08
|
|
|
CARDIZEM CD (DILTIA 120MG/1CAP
|
Facility
|
OP
|
$5.01
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
25000381
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Aetna Commercial |
$3.86
|
| Rate for Payer: Anthem Medicaid |
$1.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.91
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna Commercial |
$4.16
|
| Rate for Payer: First Health Commercial |
$4.76
|
| Rate for Payer: Humana Commercial |
$4.26
|
| Rate for Payer: Humana KY Medicaid |
$1.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.41
|
| Rate for Payer: Ohio Health Group HMO |
$3.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.55
|
| Rate for Payer: PHCS Commercial |
$4.81
|
| Rate for Payer: United Healthcare All Payer |
$4.41
|
|
|
CARDIZEM CD (DILTIA 120MG/1CAP
|
Facility
|
IP
|
$5.01
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
25000381
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Aetna Commercial |
$3.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.91
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna Commercial |
$4.16
|
| Rate for Payer: First Health Commercial |
$4.76
|
| Rate for Payer: Humana Commercial |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.41
|
| Rate for Payer: Ohio Health Group HMO |
$3.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.55
|
| Rate for Payer: PHCS Commercial |
$4.81
|
| Rate for Payer: United Healthcare All Payer |
$4.41
|
|
|
CARDIZEM CD (DILTIA 180MG/1CAP
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 50742024990
|
| Hospital Charge Code |
25000382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
CARDIZEM CD (DILTIA 180MG/1CAP
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 50742024990
|
| Hospital Charge Code |
25000382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
CARDIZEM CD (DILTIA 240MG/1CAP
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 904721961
|
| Hospital Charge Code |
25000383
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.45
|
| Rate for Payer: Humana Commercial |
$3.98
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.12
|
| Rate for Payer: Ohio Health Group HMO |
$3.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
CARDIZEM CD (DILTIA 240MG/1CAP
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 904721961
|
| Hospital Charge Code |
25000383
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.45
|
| Rate for Payer: Humana Commercial |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.12
|
| Rate for Payer: Ohio Health Group HMO |
$3.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
CARDIZEM CD (DILTIA 300MG/1CAP
|
Facility
|
OP
|
$9.03
|
|
|
Service Code
|
NDC 62037060090
|
| Hospital Charge Code |
25000384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.67 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.04
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cigna Commercial |
$7.49
|
| Rate for Payer: First Health Commercial |
$8.58
|
| Rate for Payer: Humana Commercial |
$7.68
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.95
|
| Rate for Payer: Ohio Health Group HMO |
$6.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.80
|
| Rate for Payer: PHCS Commercial |
$8.67
|
| Rate for Payer: United Healthcare All Payer |
$7.95
|
|
|
CARDIZEM CD (DILTIA 300MG/1CAP
|
Facility
|
IP
|
$9.03
|
|
|
Service Code
|
NDC 62037060090
|
| Hospital Charge Code |
25000384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.67 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.04
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cigna Commercial |
$7.49
|
| Rate for Payer: First Health Commercial |
$8.58
|
| Rate for Payer: Humana Commercial |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.95
|
| Rate for Payer: Ohio Health Group HMO |
$6.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.80
|
| Rate for Payer: PHCS Commercial |
$8.67
|
| Rate for Payer: United Healthcare All Payer |
$7.95
|
|
|
CARDIZEM (DILTIAZEM)125MG/25ML
|
Facility
|
OP
|
$116.10
|
|
|
Service Code
|
NDC 641601501
|
| Hospital Charge Code |
25002930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$111.46 |
| Rate for Payer: Aetna Commercial |
$89.40
|
| Rate for Payer: Anthem Medicaid |
$39.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.56
|
| Rate for Payer: Cash Price |
$58.05
|
| Rate for Payer: Cigna Commercial |
$96.36
|
| Rate for Payer: First Health Commercial |
$110.30
|
| Rate for Payer: Humana Commercial |
$98.68
|
| Rate for Payer: Humana KY Medicaid |
$39.93
|
| Rate for Payer: Kentucky WC Medicaid |
$40.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.17
|
| Rate for Payer: Ohio Health Group HMO |
$87.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.99
|
| Rate for Payer: PHCS Commercial |
$111.46
|
| Rate for Payer: United Healthcare All Payer |
$102.17
|
|
|
CARDIZEM (DILTIAZEM)125MG/25ML
|
Facility
|
IP
|
$116.10
|
|
|
Service Code
|
NDC 641601501
|
| Hospital Charge Code |
25002930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$111.46 |
| Rate for Payer: Aetna Commercial |
$89.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.56
|
| Rate for Payer: Cash Price |
$58.05
|
| Rate for Payer: Cigna Commercial |
$96.36
|
| Rate for Payer: First Health Commercial |
$110.30
|
| Rate for Payer: Humana Commercial |
$98.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.17
|
| Rate for Payer: Ohio Health Group HMO |
$87.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.99
|
| Rate for Payer: PHCS Commercial |
$111.46
|
| Rate for Payer: United Healthcare All Payer |
$102.17
|
|
|
CARDIZEM (DILTIAZEM) 25MG/5ML
|
Facility
|
IP
|
$78.18
|
|
|
Service Code
|
NDC 641601301
|
| Hospital Charge Code |
25002929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$60.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.98
|
| Rate for Payer: Cash Price |
$39.09
|
| Rate for Payer: Cigna Commercial |
$64.89
|
| Rate for Payer: First Health Commercial |
$74.27
|
| Rate for Payer: Humana Commercial |
$66.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.80
|
| Rate for Payer: Ohio Health Group HMO |
$58.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.24
|
| Rate for Payer: PHCS Commercial |
$75.05
|
| Rate for Payer: United Healthcare All Payer |
$68.80
|
|
|
CARDIZEM (DILTIAZEM) 25MG/5ML
|
Facility
|
OP
|
$78.18
|
|
|
Service Code
|
NDC 641601301
|
| Hospital Charge Code |
25002929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$60.20
|
| Rate for Payer: Anthem Medicaid |
$26.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.98
|
| Rate for Payer: Cash Price |
$39.09
|
| Rate for Payer: Cigna Commercial |
$64.89
|
| Rate for Payer: First Health Commercial |
$74.27
|
| Rate for Payer: Humana Commercial |
$66.45
|
| Rate for Payer: Humana KY Medicaid |
$26.89
|
| Rate for Payer: Kentucky WC Medicaid |
$27.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.80
|
| Rate for Payer: Ohio Health Group HMO |
$58.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.24
|
| Rate for Payer: PHCS Commercial |
$75.05
|
| Rate for Payer: United Healthcare All Payer |
$68.80
|
|
|
CARDIZEM (DILTIAZEM) 30MG/1TAB
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
25000378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
CARDIZEM (DILTIAZEM) 30MG/1TAB
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
25000378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
CARDIZEM (DILTIAZEM) 60MG/1TAB
|
Facility
|
IP
|
$9.31
|
|
|
Service Code
|
NDC 68682000710
|
| Hospital Charge Code |
25000379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.94 |
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.26
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.73
|
| 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 |
$6.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.19
|
| Rate for Payer: Ohio Health Group HMO |
$6.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.94
|
| Rate for Payer: United Healthcare All Payer |
$8.19
|
|
|
CARDIZEM (DILTIAZEM) 60MG/1TAB
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 68682000710
|
| Hospital Charge Code |
25000379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.94 |
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Anthem Medicaid |
$3.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.26
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.73
|
| 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 |
$6.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.19
|
| Rate for Payer: Ohio Health Group HMO |
$6.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.94
|
| Rate for Payer: United Healthcare All Payer |
$8.19
|
|
|
CARDIZEM (DILTIAZEM) 90MG/1TAB
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 51079074720
|
| Hospital Charge Code |
25000380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
CARDIZEM (DILTIAZEM) 90MG/1TAB
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 51079074720
|
| Hospital Charge Code |
25000380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
CARDIZEM SR (DILTIAZ 60MG/1CAP
|
Facility
|
IP
|
$11.31
|
|
|
Service Code
|
NDC 51079092420
|
| Hospital Charge Code |
25000385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Aetna Commercial |
$8.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.82
|
| Rate for Payer: Cash Price |
$5.66
|
| Rate for Payer: Cigna Commercial |
$9.39
|
| Rate for Payer: First Health Commercial |
$10.74
|
| Rate for Payer: Humana Commercial |
$9.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.95
|
| Rate for Payer: Ohio Health Group HMO |
$8.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$10.86
|
| Rate for Payer: United Healthcare All Payer |
$9.95
|
|
|
CARDIZEM SR (DILTIAZ 60MG/1CAP
|
Facility
|
OP
|
$11.31
|
|
|
Service Code
|
NDC 51079092420
|
| Hospital Charge Code |
25000385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Aetna Commercial |
$8.71
|
| Rate for Payer: Anthem Medicaid |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.82
|
| Rate for Payer: Cash Price |
$5.66
|
| Rate for Payer: Cigna Commercial |
$9.39
|
| Rate for Payer: First Health Commercial |
$10.74
|
| Rate for Payer: Humana Commercial |
$9.61
|
| Rate for Payer: Humana KY Medicaid |
$3.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.95
|
| Rate for Payer: Ohio Health Group HMO |
$8.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$10.86
|
| Rate for Payer: United Healthcare All Payer |
$9.95
|
|
|
CARDIZEM SR (DILTIAZ 90MG/1CAP
|
Facility
|
IP
|
$11.89
|
|
|
Service Code
|
NDC 51079092520
|
| Hospital Charge Code |
25000386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$11.41 |
| Rate for Payer: Aetna Commercial |
$9.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.27
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna Commercial |
$9.87
|
| Rate for Payer: First Health Commercial |
$11.30
|
| Rate for Payer: Humana Commercial |
$10.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.46
|
| Rate for Payer: Ohio Health Group HMO |
$8.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.69
|
| Rate for Payer: PHCS Commercial |
$11.41
|
| Rate for Payer: United Healthcare All Payer |
$10.46
|
|
|
CARDIZEM SR (DILTIAZ 90MG/1CAP
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 51079092520
|
| Hospital Charge Code |
25000386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$11.41 |
| Rate for Payer: Anthem Medicaid |
$4.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.27
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna Commercial |
$9.87
|
| Rate for Payer: First Health Commercial |
$11.30
|
| Rate for Payer: Humana Commercial |
$10.11
|
| Rate for Payer: Humana KY Medicaid |
$4.09
|
| Rate for Payer: Kentucky WC Medicaid |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.46
|
| Rate for Payer: Ohio Health Group HMO |
$8.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.69
|
| Rate for Payer: PHCS Commercial |
$11.41
|
| Rate for Payer: United Healthcare All Payer |
$10.46
|
| Rate for Payer: Aetna Commercial |
$9.16
|
|
