|
CARDIZEM CD (DILTIA 180MG/1CAP
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 50742024990
|
| Hospital Charge Code |
25000382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
CARDIZEM CD (DILTIA 180MG/1CAP
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 50742024990
|
| Hospital Charge Code |
25000382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| 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 |
$1.40 |
| 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 |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.23
|
| 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 |
$1.40 |
| 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 |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.23
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
CARDIZEM CD (DILTIA 300MG/1CAP
|
Facility
|
IP
|
$9.03
|
|
|
Service Code
|
NDC 62037060090
|
| Hospital Charge Code |
25000384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| 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 |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.23
|
| Rate for Payer: PHCS Commercial |
$8.67
|
| Rate for Payer: United Healthcare All Payer |
$7.95
|
|
|
CARDIZEM CD (DILTIA 300MG/1CAP
|
Facility
|
OP
|
$9.03
|
|
|
Service Code
|
NDC 62037060090
|
| Hospital Charge Code |
25000384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| 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 |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.23
|
| 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 |
$34.83 |
| 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 |
$98.69
|
| 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 |
$92.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.11
|
| 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 |
$34.83 |
| 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 |
$98.69
|
| 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 |
$92.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.11
|
| 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 |
$23.45 |
| 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 |
$58.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.94
|
| 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 |
$23.45 |
| 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 |
$58.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.94
|
| Rate for Payer: PHCS Commercial |
$75.05
|
| Rate for Payer: United Healthcare All Payer |
$68.80
|
|
|
CARDIZEM (DILTIAZEM) 30MG/1TAB
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
25000378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
CARDIZEM (DILTIAZEM) 30MG/1TAB
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
25000378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| 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 |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
CARDIZEM (DILTIAZEM) 60MG/1TAB
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 68682000710
|
| Hospital Charge Code |
25000379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| 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 |
$7.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.42
|
| Rate for Payer: PHCS Commercial |
$8.94
|
| Rate for Payer: United Healthcare All Payer |
$8.19
|
|
|
CARDIZEM (DILTIAZEM) 60MG/1TAB
|
Facility
|
IP
|
$9.31
|
|
|
Service Code
|
NDC 68682000710
|
| Hospital Charge Code |
25000379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| 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 |
$7.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.42
|
| 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 |
$1.37 |
| 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 |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| 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 |
$1.37 |
| 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 |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| 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 |
$3.39 |
| 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 |
$9.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.80
|
| 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 |
$3.39 |
| 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 |
$9.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.80
|
| Rate for Payer: PHCS Commercial |
$10.86
|
| Rate for Payer: United Healthcare All Payer |
$9.95
|
|
|
CARDIZEM SR (DILTIAZ 90MG/1CAP
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 51079092520
|
| Hospital Charge Code |
25000386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$11.41 |
| Rate for Payer: Aetna Commercial |
$9.16
|
| 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 |
$9.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.20
|
| Rate for Payer: PHCS Commercial |
$11.41
|
| Rate for Payer: United Healthcare All Payer |
$10.46
|
|
|
CARDIZEM SR (DILTIAZ 90MG/1CAP
|
Facility
|
IP
|
$11.89
|
|
|
Service Code
|
NDC 51079092520
|
| Hospital Charge Code |
25000386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| 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 |
$9.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.20
|
| Rate for Payer: PHCS Commercial |
$11.41
|
| Rate for Payer: United Healthcare All Payer |
$10.46
|
|
|
CARD MRI VELOC FLOW MAPPING
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
HCPCS 75565
|
| Hospital Charge Code |
61000046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$285.00 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Aetna Commercial |
$731.50
|
| Rate for Payer: Anthem Medicaid |
$326.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$741.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$788.50
|
| Rate for Payer: First Health Commercial |
$902.50
|
| Rate for Payer: Humana Commercial |
$807.50
|
| Rate for Payer: Humana KY Medicaid |
$326.70
|
| Rate for Payer: Kentucky WC Medicaid |
$330.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$779.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$701.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$285.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$333.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$836.00
|
| Rate for Payer: Ohio Health Group HMO |
$712.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$826.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$655.50
|
| Rate for Payer: PHCS Commercial |
$912.00
|
| Rate for Payer: United Healthcare All Payer |
$836.00
|
|
|
CARD MRI VELOC FLOW MAPPING
|
Facility
|
IP
|
$950.00
|
|
|
Service Code
|
HCPCS 75565
|
| Hospital Charge Code |
61000046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$285.00 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Aetna Commercial |
$731.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$741.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$788.50
|
| Rate for Payer: First Health Commercial |
$902.50
|
| Rate for Payer: Humana Commercial |
$807.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$779.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$701.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$285.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$836.00
|
| Rate for Payer: Ohio Health Group HMO |
$712.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$826.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$655.50
|
| Rate for Payer: PHCS Commercial |
$912.00
|
| Rate for Payer: United Healthcare All Payer |
$836.00
|
|
|
CARD MRI VELOC FLOW MAPPING
|
Professional
|
Both
|
$950.00
|
|
|
Service Code
|
HCPCS 75565
|
| Hospital Charge Code |
61000046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$15.95 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$137.32
|
| Rate for Payer: Ambetter Exchange |
$40.84
|
| Rate for Payer: Anthem Medicaid |
$65.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$40.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.01
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$141.05
|
| Rate for Payer: Healthspan PPO |
$74.24
|
| Rate for Payer: Humana Medicaid |
$65.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$40.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.81
|
| Rate for Payer: Molina Healthcare Passport |
$65.50
|
| Rate for Payer: Multiplan PHCS |
$570.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$53.09
|
| Rate for Payer: UHCCP Medicaid |
$332.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$40.84
|
|
|
CARD MRI VELOC FLOW MAPPING(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 75565
|
| Hospital Charge Code |
610P0046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$141.05 |
| Rate for Payer: Aetna Commercial |
$137.32
|
| Rate for Payer: Ambetter Exchange |
$40.84
|
| Rate for Payer: Anthem Medicaid |
$65.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$40.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.01
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$141.05
|
| Rate for Payer: Healthspan PPO |
$74.24
|
| Rate for Payer: Humana Medicaid |
$65.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$40.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.81
|
| Rate for Payer: Molina Healthcare Passport |
$65.50
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$53.09
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$40.84
|
|
|
CARD MRI VELOC FLOW MAPPING(T
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
HCPCS 75565
|
| Hospital Charge Code |
610T0046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$273.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$791.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.90
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
