|
CLEOCIN PED 75MG/5MLSOL 100ML
|
Facility
|
IP
|
$9.63
|
|
|
Service Code
|
NDC 9076004
|
| Hospital Charge Code |
25002945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cigna Commercial |
$7.99
|
| Rate for Payer: First Health Commercial |
$9.15
|
| Rate for Payer: Humana Commercial |
$8.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.64
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
CLEOCIN T(CLINDAMYCIN) 1% 30ML
|
Facility
|
IP
|
$6.61
|
|
|
Service Code
|
NDC 45802056201
|
| Hospital Charge Code |
25000426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$5.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.16
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna Commercial |
$5.49
|
| Rate for Payer: First Health Commercial |
$6.28
|
| Rate for Payer: Humana Commercial |
$5.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.82
|
| Rate for Payer: Ohio Health Group HMO |
$4.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.56
|
| Rate for Payer: PHCS Commercial |
$6.35
|
| Rate for Payer: United Healthcare All Payer |
$5.82
|
|
|
CLEOCIN T(CLINDAMYCIN) 1% 30ML
|
Facility
|
OP
|
$6.61
|
|
|
Service Code
|
NDC 45802056201
|
| Hospital Charge Code |
25000426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$5.09
|
| Rate for Payer: Anthem Medicaid |
$2.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5.16
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna Commercial |
$5.49
|
| Rate for Payer: First Health Commercial |
$6.28
|
| Rate for Payer: Humana Commercial |
$5.62
|
| Rate for Payer: Humana KY Medicaid |
$2.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.82
|
| Rate for Payer: Ohio Health Group HMO |
$4.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.56
|
| Rate for Payer: PHCS Commercial |
$6.35
|
| Rate for Payer: United Healthcare All Payer |
$5.82
|
|
|
CLEOCIN T GEL 1% GEL (60GM)
|
Facility
|
IP
|
$9.04
|
|
|
Service Code
|
NDC 59762374302
|
| Hospital Charge Code |
25000425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Aetna Commercial |
$6.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.05
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cigna Commercial |
$7.50
|
| Rate for Payer: First Health Commercial |
$8.59
|
| Rate for Payer: Humana Commercial |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.68
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
CLEOCIN T GEL 1% GEL (60GM)
|
Facility
|
OP
|
$9.04
|
|
|
Service Code
|
NDC 59762374302
|
| Hospital Charge Code |
25000425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Aetna Commercial |
$6.96
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.05
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cigna Commercial |
$7.50
|
| Rate for Payer: First Health Commercial |
$8.59
|
| 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 |
$7.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.68
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
[C]LIBRIUM(CHLORDIAZ 10MG/1CAP
|
Facility
|
OP
|
$60.15
|
|
|
Service Code
|
NDC 555003302
|
| Hospital Charge Code |
25000100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Anthem Medicaid |
$20.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.92
|
| Rate for Payer: First Health Commercial |
$57.14
|
| Rate for Payer: Humana Commercial |
$51.13
|
| Rate for Payer: Humana KY Medicaid |
$20.69
|
| Rate for Payer: Kentucky WC Medicaid |
$20.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.93
|
| Rate for Payer: Ohio Health Group HMO |
$45.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.50
|
| Rate for Payer: PHCS Commercial |
$57.74
|
| Rate for Payer: United Healthcare All Payer |
$52.93
|
|
|
[C]LIBRIUM(CHLORDIAZ 10MG/1CAP
|
Facility
|
IP
|
$60.15
|
|
|
Service Code
|
NDC 555003302
|
| Hospital Charge Code |
25000100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.92
|
| Rate for Payer: First Health Commercial |
$57.14
|
| Rate for Payer: Humana Commercial |
$51.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.93
|
| Rate for Payer: Ohio Health Group HMO |
$45.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.50
|
| Rate for Payer: PHCS Commercial |
$57.74
|
| Rate for Payer: United Healthcare All Payer |
$52.93
|
|
|
[C]LIBRIUM(CHLORDIAZ 25MG/1CAP
|
Facility
|
OP
|
$60.17
|
|
|
Service Code
|
NDC 555015902
|
| Hospital Charge Code |
25000101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.76 |
| Rate for Payer: Aetna Commercial |
$46.33
|
| Rate for Payer: Anthem Medicaid |
$20.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.93
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.94
|
| Rate for Payer: First Health Commercial |
$57.16
|
| Rate for Payer: Humana Commercial |
$51.14
|
| Rate for Payer: Humana KY Medicaid |
$20.69
|
| Rate for Payer: Kentucky WC Medicaid |
$20.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.95
|
| Rate for Payer: Ohio Health Group HMO |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.52
|
| Rate for Payer: PHCS Commercial |
$57.76
|
| Rate for Payer: United Healthcare All Payer |
$52.95
|
|
|
[C]LIBRIUM(CHLORDIAZ 25MG/1CAP
|
Facility
|
IP
|
$60.17
|
|
|
Service Code
|
NDC 555015902
|
| Hospital Charge Code |
25000101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.76 |
| Rate for Payer: Aetna Commercial |
$46.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.93
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.94
|
| Rate for Payer: First Health Commercial |
$57.16
|
| Rate for Payer: Humana Commercial |
$51.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.95
|
| Rate for Payer: Ohio Health Group HMO |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.52
|
| Rate for Payer: PHCS Commercial |
$57.76
|
| Rate for Payer: United Healthcare All Payer |
$52.95
|
|
|
[C]LIBRIUM(CHLORDIAZE 5MG/1CAP
|
Facility
|
IP
|
$60.19
|
|
|
Service Code
|
NDC 555015802
|
| Hospital Charge Code |
25000102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$57.78 |
| Rate for Payer: Aetna Commercial |
$46.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.95
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.96
|
| Rate for Payer: First Health Commercial |
$57.18
|
| Rate for Payer: Humana Commercial |
$51.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.97
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.53
|
| Rate for Payer: PHCS Commercial |
$57.78
|
| Rate for Payer: United Healthcare All Payer |
$52.97
|
|
|
[C]LIBRIUM(CHLORDIAZE 5MG/1CAP
|
Facility
|
OP
|
$60.19
|
|
|
Service Code
|
NDC 555015802
|
| Hospital Charge Code |
25000102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$57.78 |
| Rate for Payer: Aetna Commercial |
$46.35
|
| Rate for Payer: Anthem Medicaid |
$20.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.95
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.96
|
| Rate for Payer: First Health Commercial |
$57.18
|
| Rate for Payer: Humana Commercial |
$51.16
|
| 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 |
$44.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.97
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.53
|
| Rate for Payer: PHCS Commercial |
$57.78
|
| Rate for Payer: United Healthcare All Payer |
$52.97
|
|
|
CLIK X MRI ANCHOR
|
Facility
|
OP
|
$3,265.62
|
|
|
Service Code
|
HCPCS C1883
|
| Hospital Charge Code |
27000063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.69 |
| Max. Negotiated Rate |
$3,135.00 |
| Rate for Payer: Aetna Commercial |
$2,514.53
|
| Rate for Payer: Anthem Medicaid |
$1,123.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,547.18
|
| Rate for Payer: Cash Price |
$1,632.81
|
| Rate for Payer: Cigna Commercial |
$2,710.46
|
| Rate for Payer: First Health Commercial |
$3,102.34
|
| Rate for Payer: Humana Commercial |
$2,775.78
|
| Rate for Payer: Humana KY Medicaid |
$1,123.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,134.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,677.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,410.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$979.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,145.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,873.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,449.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,612.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,841.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,253.28
|
| Rate for Payer: PHCS Commercial |
$3,135.00
|
| Rate for Payer: United Healthcare All Payer |
$2,873.75
|
|
|
CLIK X MRI ANCHOR
|
Facility
|
IP
|
$3,265.62
|
|
|
Service Code
|
HCPCS C1883
|
| Hospital Charge Code |
27000063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.69 |
| Max. Negotiated Rate |
$3,135.00 |
| Rate for Payer: Aetna Commercial |
$2,514.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,547.18
|
| Rate for Payer: Cash Price |
$1,632.81
|
| Rate for Payer: Cigna Commercial |
$2,710.46
|
| Rate for Payer: First Health Commercial |
$3,102.34
|
| Rate for Payer: Humana Commercial |
$2,775.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,677.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,410.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$979.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,873.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,449.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,612.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,841.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,253.28
|
| Rate for Payer: PHCS Commercial |
$3,135.00
|
| Rate for Payer: United Healthcare All Payer |
$2,873.75
|
|
|
CLIMARA (ESTRADIOL) 0 .1MG/1EA
|
Facility
|
IP
|
$36.08
|
|
|
Service Code
|
NDC 50419045204
|
| Hospital Charge Code |
25000430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$34.64 |
| Rate for Payer: Aetna Commercial |
$27.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.14
|
| Rate for Payer: Cash Price |
$18.04
|
| Rate for Payer: Cigna Commercial |
$29.95
|
| Rate for Payer: First Health Commercial |
$34.28
|
| Rate for Payer: Humana Commercial |
$30.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.75
|
| Rate for Payer: Ohio Health Group HMO |
$27.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.90
|
| Rate for Payer: PHCS Commercial |
$34.64
|
| Rate for Payer: United Healthcare All Payer |
$31.75
|
|
|
CLIMARA (ESTRADIOL) 0 .1MG/1EA
|
Facility
|
OP
|
$36.08
|
|
|
Service Code
|
NDC 50419045204
|
| Hospital Charge Code |
25000430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$34.64 |
| Rate for Payer: Aetna Commercial |
$27.78
|
| Rate for Payer: Anthem Medicaid |
$12.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.14
|
| Rate for Payer: Cash Price |
$18.04
|
| Rate for Payer: Cigna Commercial |
$29.95
|
| Rate for Payer: First Health Commercial |
$34.28
|
| Rate for Payer: Humana Commercial |
$30.67
|
| Rate for Payer: Humana KY Medicaid |
$12.41
|
| Rate for Payer: Kentucky WC Medicaid |
$12.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.75
|
| Rate for Payer: Ohio Health Group HMO |
$27.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.90
|
| Rate for Payer: PHCS Commercial |
$34.64
|
| Rate for Payer: United Healthcare All Payer |
$31.75
|
|
|
CLIMARA (ESTRADIOL) .05MG/1EA
|
Facility
|
IP
|
$35.56
|
|
|
Service Code
|
NDC 378335016
|
| Hospital Charge Code |
25000429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.67 |
| Max. Negotiated Rate |
$34.14 |
| Rate for Payer: Aetna Commercial |
$27.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.74
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cigna Commercial |
$29.51
|
| Rate for Payer: First Health Commercial |
$33.78
|
| Rate for Payer: Humana Commercial |
$30.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.29
|
| Rate for Payer: Ohio Health Group HMO |
$26.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.54
|
| Rate for Payer: PHCS Commercial |
$34.14
|
| Rate for Payer: United Healthcare All Payer |
$31.29
|
|
|
CLIMARA (ESTRADIOL) .05MG/1EA
|
Facility
|
OP
|
$35.56
|
|
|
Service Code
|
NDC 378335016
|
| Hospital Charge Code |
25000429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.67 |
| Max. Negotiated Rate |
$34.14 |
| Rate for Payer: Aetna Commercial |
$27.38
|
| Rate for Payer: Anthem Medicaid |
$12.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.74
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cigna Commercial |
$29.51
|
| Rate for Payer: First Health Commercial |
$33.78
|
| Rate for Payer: Humana Commercial |
$30.23
|
| Rate for Payer: Humana KY Medicaid |
$12.23
|
| Rate for Payer: Kentucky WC Medicaid |
$12.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.29
|
| Rate for Payer: Ohio Health Group HMO |
$26.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.54
|
| Rate for Payer: PHCS Commercial |
$34.14
|
| Rate for Payer: United Healthcare All Payer |
$31.29
|
|
|
[C]LIMBITROL (CHLORD/AMIT)1TAB
|
Facility
|
IP
|
$61.23
|
|
|
Service Code
|
NDC 378021101
|
| Hospital Charge Code |
25000103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$58.78 |
| Rate for Payer: Aetna Commercial |
$47.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.76
|
| Rate for Payer: Cash Price |
$30.61
|
| Rate for Payer: Cigna Commercial |
$50.82
|
| Rate for Payer: First Health Commercial |
$58.17
|
| Rate for Payer: Humana Commercial |
$52.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.88
|
| Rate for Payer: Ohio Health Group HMO |
$45.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.25
|
| Rate for Payer: PHCS Commercial |
$58.78
|
| Rate for Payer: United Healthcare All Payer |
$53.88
|
|
|
[C]LIMBITROL (CHLORD/AMIT)1TAB
|
Facility
|
OP
|
$61.23
|
|
|
Service Code
|
NDC 378021101
|
| Hospital Charge Code |
25000103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$58.78 |
| Rate for Payer: Aetna Commercial |
$47.15
|
| Rate for Payer: Anthem Medicaid |
$21.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.76
|
| Rate for Payer: Cash Price |
$30.61
|
| Rate for Payer: Cigna Commercial |
$50.82
|
| Rate for Payer: First Health Commercial |
$58.17
|
| Rate for Payer: Humana Commercial |
$52.05
|
| Rate for Payer: Humana KY Medicaid |
$21.06
|
| Rate for Payer: Kentucky WC Medicaid |
$21.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.88
|
| Rate for Payer: Ohio Health Group HMO |
$45.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.25
|
| Rate for Payer: PHCS Commercial |
$58.78
|
| Rate for Payer: United Healthcare All Payer |
$53.88
|
|
|
CLINDAMYCIN 1% LOTION(60ML)
|
Facility
|
IP
|
$11.04
|
|
|
Service Code
|
NDC 59762374401
|
| Hospital Charge Code |
25003726
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Aetna Commercial |
$8.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.61
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Cigna Commercial |
$9.16
|
| Rate for Payer: First Health Commercial |
$10.49
|
| Rate for Payer: Humana Commercial |
$9.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.72
|
| Rate for Payer: Ohio Health Group HMO |
$8.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.62
|
| Rate for Payer: PHCS Commercial |
$10.60
|
| Rate for Payer: United Healthcare All Payer |
$9.72
|
|
|
CLINDAMYCIN 1% LOTION(60ML)
|
Facility
|
OP
|
$11.04
|
|
|
Service Code
|
NDC 59762374401
|
| Hospital Charge Code |
25003726
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Aetna Commercial |
$8.50
|
| Rate for Payer: Anthem Medicaid |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.61
|
| Rate for Payer: Cash Price |
$5.52
|
| Rate for Payer: Cigna Commercial |
$9.16
|
| Rate for Payer: First Health Commercial |
$10.49
|
| Rate for Payer: Humana Commercial |
$9.38
|
| Rate for Payer: Humana KY Medicaid |
$3.80
|
| Rate for Payer: Kentucky WC Medicaid |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.72
|
| Rate for Payer: Ohio Health Group HMO |
$8.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.62
|
| Rate for Payer: PHCS Commercial |
$10.60
|
| Rate for Payer: United Healthcare All Payer |
$9.72
|
|
|
CLINDAMYCIN(GENERIC)300MG/50ML
|
Facility
|
IP
|
$114.08
|
|
|
Service Code
|
HCPCS J0736
|
| Hospital Charge Code |
25004210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.22 |
| Max. Negotiated Rate |
$109.52 |
| Rate for Payer: Aetna Commercial |
$87.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.98
|
| Rate for Payer: Cash Price |
$57.04
|
| Rate for Payer: Cigna Commercial |
$94.69
|
| Rate for Payer: First Health Commercial |
$108.38
|
| Rate for Payer: Humana Commercial |
$96.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.39
|
| Rate for Payer: Ohio Health Group HMO |
$85.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.72
|
| Rate for Payer: PHCS Commercial |
$109.52
|
| Rate for Payer: United Healthcare All Payer |
$100.39
|
|
|
CLINDAMYCIN(GENERIC)300MG/50ML
|
Facility
|
OP
|
$114.08
|
|
|
Service Code
|
HCPCS J0736
|
| Hospital Charge Code |
25004210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.22 |
| Max. Negotiated Rate |
$109.52 |
| Rate for Payer: Aetna Commercial |
$87.84
|
| Rate for Payer: Anthem Medicaid |
$39.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.98
|
| Rate for Payer: Cash Price |
$57.04
|
| Rate for Payer: Cigna Commercial |
$94.69
|
| Rate for Payer: First Health Commercial |
$108.38
|
| Rate for Payer: Humana Commercial |
$96.97
|
| Rate for Payer: Humana KY Medicaid |
$39.23
|
| Rate for Payer: Kentucky WC Medicaid |
$39.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.39
|
| Rate for Payer: Ohio Health Group HMO |
$85.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.72
|
| Rate for Payer: PHCS Commercial |
$109.52
|
| Rate for Payer: United Healthcare All Payer |
$100.39
|
|
|
CLINDAMYCIN(GENERIC)600MG/50ML
|
Facility
|
OP
|
$118.87
|
|
|
Service Code
|
HCPCS J0736
|
| Hospital Charge Code |
25004211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.66 |
| Max. Negotiated Rate |
$114.12 |
| Rate for Payer: Aetna Commercial |
$91.53
|
| Rate for Payer: Anthem Medicaid |
$40.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.72
|
| Rate for Payer: Cash Price |
$59.44
|
| Rate for Payer: Cigna Commercial |
$98.66
|
| Rate for Payer: First Health Commercial |
$112.93
|
| Rate for Payer: Humana Commercial |
$101.04
|
| Rate for Payer: Humana KY Medicaid |
$40.88
|
| Rate for Payer: Kentucky WC Medicaid |
$41.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.61
|
| Rate for Payer: Ohio Health Group HMO |
$89.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.02
|
| Rate for Payer: PHCS Commercial |
$114.12
|
| Rate for Payer: United Healthcare All Payer |
$104.61
|
|
|
CLINDAMYCIN(GENERIC)600MG/50ML
|
Facility
|
IP
|
$118.87
|
|
|
Service Code
|
HCPCS J0736
|
| Hospital Charge Code |
25004211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.66 |
| Max. Negotiated Rate |
$114.12 |
| Rate for Payer: Aetna Commercial |
$91.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.72
|
| Rate for Payer: Cash Price |
$59.44
|
| Rate for Payer: Cigna Commercial |
$98.66
|
| Rate for Payer: First Health Commercial |
$112.93
|
| Rate for Payer: Humana Commercial |
$101.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.61
|
| Rate for Payer: Ohio Health Group HMO |
$89.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.02
|
| Rate for Payer: PHCS Commercial |
$114.12
|
| Rate for Payer: United Healthcare All Payer |
$104.61
|
|
