|
DALIRESP 500MCG TABLET
|
Facility
|
OP
|
$5.07
|
|
|
Service Code
|
NDC 68382096906
|
| Hospital Charge Code |
25000511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.87 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.21
|
| Rate for Payer: First Health Commercial |
$4.82
|
| Rate for Payer: Humana Commercial |
$4.31
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.46
|
| Rate for Payer: Ohio Health Group HMO |
$3.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.87
|
| Rate for Payer: United Healthcare All Payer |
$4.46
|
|
|
DALL-MILES GRIP W/ 2 CBL MED 1
|
Facility
|
IP
|
$11,012.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.57 |
| Max. Negotiated Rate |
$10,571.60 |
| Rate for Payer: Aetna Commercial |
$8,479.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,589.42
|
| Rate for Payer: Cash Price |
$5,506.04
|
| Rate for Payer: Cigna Commercial |
$9,140.03
|
| Rate for Payer: First Health Commercial |
$10,461.48
|
| Rate for Payer: Humana Commercial |
$9,360.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,029.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,126.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,303.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,690.63
|
| Rate for Payer: Ohio Health Group HMO |
$8,259.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,202.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,431.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,413.74
|
| Rate for Payer: PHCS Commercial |
$10,571.60
|
| Rate for Payer: United Healthcare All Payer |
$9,690.63
|
|
|
DALL-MILES GRIP W/ 2 CBL MED 1
|
Facility
|
OP
|
$11,012.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.57 |
| Max. Negotiated Rate |
$10,571.60 |
| Rate for Payer: Aetna Commercial |
$8,479.30
|
| Rate for Payer: Anthem Medicaid |
$3,787.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,589.42
|
| Rate for Payer: Cash Price |
$5,506.04
|
| Rate for Payer: Cigna Commercial |
$9,140.03
|
| Rate for Payer: First Health Commercial |
$10,461.48
|
| Rate for Payer: Humana Commercial |
$9,360.27
|
| Rate for Payer: Humana KY Medicaid |
$3,787.05
|
| Rate for Payer: Kentucky WC Medicaid |
$3,825.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,029.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,126.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,303.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,863.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,690.63
|
| Rate for Payer: Ohio Health Group HMO |
$8,259.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,202.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,431.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,413.74
|
| Rate for Payer: PHCS Commercial |
$10,571.60
|
| Rate for Payer: United Healthcare All Payer |
$9,690.63
|
|
|
DALL-MILES GRP W/2 CBL M 100MM
|
Facility
|
OP
|
$7,545.47
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.91 |
| Max. Negotiated Rate |
$7,243.65 |
| Rate for Payer: Aetna Commercial |
$5,810.01
|
| Rate for Payer: Anthem Medicaid |
$2,594.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.47
|
| Rate for Payer: Cash Price |
$3,772.74
|
| Rate for Payer: Cigna Commercial |
$6,262.74
|
| Rate for Payer: First Health Commercial |
$7,168.20
|
| Rate for Payer: Humana Commercial |
$6,413.65
|
| Rate for Payer: Humana KY Medicaid |
$2,594.89
|
| Rate for Payer: Kentucky WC Medicaid |
$2,621.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,187.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,646.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,640.01
|
| Rate for Payer: Ohio Health Group HMO |
$5,659.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,339.10
|
| Rate for Payer: PHCS Commercial |
$7,243.65
|
| Rate for Payer: United Healthcare All Payer |
$6,640.01
|
|
|
DALL-MILES GRP W/2 CBL M 100MM
|
Facility
|
IP
|
$7,545.47
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.91 |
| Max. Negotiated Rate |
$7,243.65 |
| Rate for Payer: Aetna Commercial |
$5,810.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.47
|
| Rate for Payer: Cash Price |
$3,772.74
|
| Rate for Payer: Cigna Commercial |
$6,262.74
|
| Rate for Payer: First Health Commercial |
$7,168.20
|
| Rate for Payer: Humana Commercial |
$6,413.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,187.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,640.01
|
| Rate for Payer: Ohio Health Group HMO |
$5,659.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,339.10
|
| Rate for Payer: PHCS Commercial |
$7,243.65
|
| Rate for Payer: United Healthcare All Payer |
$6,640.01
|
|
|
DALL-MILES TROCHGRIP W/CBL MED
|
Facility
|
IP
|
$7,920.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,029.63 |
| Max. Negotiated Rate |
$7,603.41 |
| Rate for Payer: Aetna Commercial |
$6,098.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,177.77
|
| Rate for Payer: Cash Price |
$3,960.11
|
| Rate for Payer: Cigna Commercial |
$6,573.78
|
| Rate for Payer: First Health Commercial |
$7,524.21
|
| Rate for Payer: Humana Commercial |
$6,732.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,494.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,845.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,376.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,969.79
|
| Rate for Payer: Ohio Health Group HMO |
$5,940.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,584.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,029.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,455.27
|
| Rate for Payer: PHCS Commercial |
$7,603.41
|
| Rate for Payer: United Healthcare All Payer |
$6,969.79
|
|
|
DALL-MILES TROCHGRIP W/CBL MED
|
Facility
|
OP
|
$7,920.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,029.63 |
| Max. Negotiated Rate |
$7,603.41 |
| Rate for Payer: Aetna Commercial |
$6,098.57
|
| Rate for Payer: Anthem Medicaid |
$2,723.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,177.77
|
| Rate for Payer: Cash Price |
$3,960.11
|
| Rate for Payer: Cigna Commercial |
$6,573.78
|
| Rate for Payer: First Health Commercial |
$7,524.21
|
| Rate for Payer: Humana Commercial |
$6,732.19
|
| Rate for Payer: Humana KY Medicaid |
$2,723.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,751.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,494.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,845.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,376.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,778.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,969.79
|
| Rate for Payer: Ohio Health Group HMO |
$5,940.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,584.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,029.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,455.27
|
| Rate for Payer: PHCS Commercial |
$7,603.41
|
| Rate for Payer: United Healthcare All Payer |
$6,969.79
|
|
|
DALL-MILES TROCH GRIP W/CBL SM
|
Facility
|
IP
|
$8,336.68
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,083.77 |
| Max. Negotiated Rate |
$8,003.21 |
| Rate for Payer: Aetna Commercial |
$6,419.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,502.61
|
| Rate for Payer: Cash Price |
$4,168.34
|
| Rate for Payer: Cigna Commercial |
$6,919.44
|
| Rate for Payer: First Health Commercial |
$7,919.85
|
| Rate for Payer: Humana Commercial |
$7,086.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,836.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,152.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,501.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,336.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,252.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,667.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,083.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,584.37
|
| Rate for Payer: PHCS Commercial |
$8,003.21
|
| Rate for Payer: United Healthcare All Payer |
$7,336.28
|
|
|
DALL-MILES TROCH GRIP W/CBL SM
|
Facility
|
OP
|
$8,336.68
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,083.77 |
| Max. Negotiated Rate |
$8,003.21 |
| Rate for Payer: Aetna Commercial |
$6,419.24
|
| Rate for Payer: Anthem Medicaid |
$2,866.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,502.61
|
| Rate for Payer: Cash Price |
$4,168.34
|
| Rate for Payer: Cigna Commercial |
$6,919.44
|
| Rate for Payer: First Health Commercial |
$7,919.85
|
| Rate for Payer: Humana Commercial |
$7,086.18
|
| Rate for Payer: Humana KY Medicaid |
$2,866.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,896.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,836.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,152.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,501.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,924.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,336.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,252.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,667.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,083.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,584.37
|
| Rate for Payer: PHCS Commercial |
$8,003.21
|
| Rate for Payer: United Healthcare All Payer |
$7,336.28
|
|
|
DALVANCE 5MG [500 MG VIAL]
|
Facility
|
OP
|
$9,696.26
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
25001972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$9,308.41 |
| Rate for Payer: Aetna Commercial |
$7,466.12
|
| Rate for Payer: Anthem Medicaid |
$3,334.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,563.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.65
|
| Rate for Payer: Cash Price |
$4,848.13
|
| Rate for Payer: Cash Price |
$4,848.13
|
| Rate for Payer: Cigna Commercial |
$8,047.90
|
| Rate for Payer: First Health Commercial |
$9,211.45
|
| Rate for Payer: Humana Commercial |
$8,241.82
|
| Rate for Payer: Humana KY Medicaid |
$3,334.54
|
| Rate for Payer: Humana Medicare Advantage |
$15.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,368.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,950.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,155.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,401.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,532.71
|
| Rate for Payer: Ohio Health Group HMO |
$7,272.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,939.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,260.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,005.84
|
| Rate for Payer: PHCS Commercial |
$9,308.41
|
| Rate for Payer: United Healthcare All Payer |
$8,532.71
|
|
|
DALVANCE 5MG [500 MG VIAL]
|
Facility
|
IP
|
$9,696.26
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
25001972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,260.51 |
| Max. Negotiated Rate |
$9,308.41 |
| Rate for Payer: Aetna Commercial |
$7,466.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,563.08
|
| Rate for Payer: Cash Price |
$4,848.13
|
| Rate for Payer: Cigna Commercial |
$8,047.90
|
| Rate for Payer: First Health Commercial |
$9,211.45
|
| Rate for Payer: Humana Commercial |
$8,241.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,950.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,155.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,908.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,532.71
|
| Rate for Payer: Ohio Health Group HMO |
$7,272.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,939.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,260.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,005.84
|
| Rate for Payer: PHCS Commercial |
$9,308.41
|
| Rate for Payer: United Healthcare All Payer |
$8,532.71
|
|
|
DANTRIUM (DANTROLENE) 20MG/1EA
|
Facility
|
IP
|
$357.64
|
|
|
Service Code
|
NDC 42023012306
|
| Hospital Charge Code |
25002982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.49 |
| Max. Negotiated Rate |
$343.33 |
| Rate for Payer: Aetna Commercial |
$275.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$278.96
|
| Rate for Payer: Cash Price |
$178.82
|
| Rate for Payer: Cigna Commercial |
$296.84
|
| Rate for Payer: First Health Commercial |
$339.76
|
| Rate for Payer: Humana Commercial |
$303.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$263.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$314.72
|
| Rate for Payer: Ohio Health Group HMO |
$268.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.87
|
| Rate for Payer: PHCS Commercial |
$343.33
|
| Rate for Payer: United Healthcare All Payer |
$314.72
|
|
|
DANTRIUM (DANTROLENE) 20MG/1EA
|
Facility
|
OP
|
$357.64
|
|
|
Service Code
|
NDC 42023012306
|
| Hospital Charge Code |
25002982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.49 |
| Max. Negotiated Rate |
$343.33 |
| Rate for Payer: Aetna Commercial |
$275.38
|
| Rate for Payer: Anthem Medicaid |
$122.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$278.96
|
| Rate for Payer: Cash Price |
$178.82
|
| Rate for Payer: Cigna Commercial |
$296.84
|
| Rate for Payer: First Health Commercial |
$339.76
|
| Rate for Payer: Humana Commercial |
$303.99
|
| Rate for Payer: Humana KY Medicaid |
$122.99
|
| Rate for Payer: Kentucky WC Medicaid |
$124.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$263.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$125.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$314.72
|
| Rate for Payer: Ohio Health Group HMO |
$268.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.87
|
| Rate for Payer: PHCS Commercial |
$343.33
|
| Rate for Payer: United Healthcare All Payer |
$314.72
|
|
|
DANTRIUM (DANTROLENE 25MG/1CAP
|
Facility
|
IP
|
$9.63
|
|
|
Service Code
|
NDC 68084030021
|
| Hospital Charge Code |
25000513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| 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 |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
DANTRIUM (DANTROLENE 25MG/1CAP
|
Facility
|
OP
|
$9.63
|
|
|
Service Code
|
NDC 68084030021
|
| Hospital Charge Code |
25000513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Anthem Medicaid |
$3.31
|
| 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: Humana KY Medicaid |
$3.31
|
| Rate for Payer: Kentucky WC Medicaid |
$3.35
|
| 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: Molina Healthcare Medicaid |
$3.38
|
| 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 |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
DANTROLENE 250mg SDV
|
Facility
|
OP
|
$4,876.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$633.98 |
| Max. Negotiated Rate |
$4,681.68 |
| Rate for Payer: Aetna Commercial |
$3,755.10
|
| Rate for Payer: Anthem Medicaid |
$1,677.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,803.86
|
| Rate for Payer: Cash Price |
$2,438.38
|
| Rate for Payer: Cigna Commercial |
$4,047.70
|
| Rate for Payer: First Health Commercial |
$4,632.91
|
| Rate for Payer: Humana Commercial |
$4,145.24
|
| Rate for Payer: Humana KY Medicaid |
$1,677.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,694.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,998.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,599.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,463.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,710.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,657.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$975.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$633.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,511.79
|
| Rate for Payer: PHCS Commercial |
$4,681.68
|
| Rate for Payer: United Healthcare All Payer |
$4,291.54
|
|
|
DANTROLENE 250mg SDV
|
Facility
|
IP
|
$4,876.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$633.98 |
| Max. Negotiated Rate |
$4,681.68 |
| Rate for Payer: Aetna Commercial |
$3,755.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,803.86
|
| Rate for Payer: Cash Price |
$2,438.38
|
| Rate for Payer: Cigna Commercial |
$4,047.70
|
| Rate for Payer: First Health Commercial |
$4,632.91
|
| Rate for Payer: Humana Commercial |
$4,145.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,998.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,599.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,463.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,657.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$975.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$633.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,511.79
|
| Rate for Payer: PHCS Commercial |
$4,681.68
|
| Rate for Payer: United Healthcare All Payer |
$4,291.54
|
|
|
DAPAKENE 500/10ML ORAL SUSP
|
Facility
|
OP
|
$10.24
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Aetna Commercial |
$7.88
|
| Rate for Payer: Anthem Medicaid |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.99
|
| Rate for Payer: Cash Price |
$5.12
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.73
|
| Rate for Payer: Humana Commercial |
$8.70
|
| Rate for Payer: Humana KY Medicaid |
$3.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.01
|
| Rate for Payer: Ohio Health Group HMO |
$7.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$9.83
|
| Rate for Payer: United Healthcare All Payer |
$9.01
|
|
|
DAPAKENE 500/10ML ORAL SUSP
|
Facility
|
IP
|
$10.24
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Aetna Commercial |
$7.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.99
|
| Rate for Payer: Cash Price |
$5.12
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.73
|
| Rate for Payer: Humana Commercial |
$8.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.01
|
| Rate for Payer: Ohio Health Group HMO |
$7.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$9.83
|
| Rate for Payer: United Healthcare All Payer |
$9.01
|
|
|
DAPSONE 100MG TABLET
|
Facility
|
IP
|
$10.42
|
|
|
Service Code
|
NDC 29033003730
|
| Hospital Charge Code |
25000515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna Commercial |
$8.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.13
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cigna Commercial |
$8.65
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: Humana Commercial |
$8.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.17
|
| Rate for Payer: Ohio Health Group HMO |
$7.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.23
|
| Rate for Payer: PHCS Commercial |
$10.00
|
| Rate for Payer: United Healthcare All Payer |
$9.17
|
|
|
DAPSONE 100MG TABLET
|
Facility
|
OP
|
$10.42
|
|
|
Service Code
|
NDC 29033003730
|
| Hospital Charge Code |
25000515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna Commercial |
$8.02
|
| Rate for Payer: Anthem Medicaid |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.13
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cigna Commercial |
$8.65
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: Humana Commercial |
$8.86
|
| Rate for Payer: Humana KY Medicaid |
$3.58
|
| Rate for Payer: Kentucky WC Medicaid |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.17
|
| Rate for Payer: Ohio Health Group HMO |
$7.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.23
|
| Rate for Payer: PHCS Commercial |
$10.00
|
| Rate for Payer: United Healthcare All Payer |
$9.17
|
|
|
DAPSONE 25MG/1TAB
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 49938010201
|
| Hospital Charge Code |
25000514
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
DAPSONE 25MG/1TAB
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 49938010201
|
| Hospital Charge Code |
25000514
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
DARZALEX 100MG/5ML VIAL
|
Facility
|
OP
|
$4,007.55
|
|
|
Service Code
|
HCPCS J9145
|
| Hospital Charge Code |
25002597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.70 |
| Max. Negotiated Rate |
$3,847.25 |
| Rate for Payer: Aetna Commercial |
$3,085.81
|
| Rate for Payer: Anthem Medicaid |
$1,378.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$61.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,125.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$86.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$83.30
|
| Rate for Payer: Cash Price |
$2,003.78
|
| Rate for Payer: Cash Price |
$2,003.78
|
| Rate for Payer: Cigna Commercial |
$3,326.27
|
| Rate for Payer: First Health Commercial |
$3,807.17
|
| Rate for Payer: Humana Commercial |
$3,406.42
|
| Rate for Payer: Humana KY Medicaid |
$1,378.20
|
| Rate for Payer: Humana Medicare Advantage |
$61.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,392.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,286.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,957.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,405.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,526.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,005.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.34
|
| Rate for Payer: PHCS Commercial |
$3,847.25
|
| Rate for Payer: United Healthcare All Payer |
$3,526.64
|
|
|
DARZALEX 100MG/5ML VIAL
|
Facility
|
IP
|
$4,007.55
|
|
|
Service Code
|
HCPCS J9145
|
| Hospital Charge Code |
25002597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$520.98 |
| Max. Negotiated Rate |
$3,847.25 |
| Rate for Payer: Aetna Commercial |
$3,085.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,125.89
|
| Rate for Payer: Cash Price |
$2,003.78
|
| Rate for Payer: Cigna Commercial |
$3,326.27
|
| Rate for Payer: First Health Commercial |
$3,807.17
|
| Rate for Payer: Humana Commercial |
$3,406.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,286.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,957.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,526.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,005.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.34
|
| Rate for Payer: PHCS Commercial |
$3,847.25
|
| Rate for Payer: United Healthcare All Payer |
$3,526.64
|
|
