|
DALL-MILES TROCHGRIP W/CBL MED
|
Facility
|
OP
|
$8,120.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,436.07 |
| Max. Negotiated Rate |
$7,795.41 |
| Rate for Payer: Aetna Commercial |
$6,252.57
|
| Rate for Payer: Anthem Medicaid |
$2,792.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,333.77
|
| Rate for Payer: Cash Price |
$4,060.11
|
| Rate for Payer: Cigna Commercial |
$6,739.78
|
| Rate for Payer: First Health Commercial |
$7,714.21
|
| Rate for Payer: Humana Commercial |
$6,902.19
|
| Rate for Payer: Humana KY Medicaid |
$2,792.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,820.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,658.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,992.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,436.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,848.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,145.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,090.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,496.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,064.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,602.95
|
| Rate for Payer: PHCS Commercial |
$7,795.41
|
| Rate for Payer: United Healthcare All Payer |
$7,145.79
|
|
|
DALL-MILES TROCHGRIP W/CBL MED
|
Facility
|
IP
|
$8,120.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,436.07 |
| Max. Negotiated Rate |
$7,795.41 |
| Rate for Payer: Aetna Commercial |
$6,252.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,333.77
|
| Rate for Payer: Cash Price |
$4,060.11
|
| Rate for Payer: Cigna Commercial |
$6,739.78
|
| Rate for Payer: First Health Commercial |
$7,714.21
|
| Rate for Payer: Humana Commercial |
$6,902.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,658.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,992.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,436.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,145.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,090.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,496.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,064.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,602.95
|
| Rate for Payer: PHCS Commercial |
$7,795.41
|
| Rate for Payer: United Healthcare All Payer |
$7,145.79
|
|
|
DALL-MILES TROCH GRIP W/CBL SM
|
Facility
|
OP
|
$8,536.68
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,561.00 |
| Max. Negotiated Rate |
$8,195.21 |
| Rate for Payer: Aetna Commercial |
$6,573.24
|
| Rate for Payer: Anthem Medicaid |
$2,935.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,658.61
|
| Rate for Payer: Cash Price |
$4,268.34
|
| Rate for Payer: Cigna Commercial |
$7,085.44
|
| Rate for Payer: First Health Commercial |
$8,109.85
|
| Rate for Payer: Humana Commercial |
$7,256.18
|
| Rate for Payer: Humana KY Medicaid |
$2,935.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,965.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,000.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,300.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,994.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,512.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,402.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,829.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,426.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,890.31
|
| Rate for Payer: PHCS Commercial |
$8,195.21
|
| Rate for Payer: United Healthcare All Payer |
$7,512.28
|
|
|
DALL-MILES TROCH GRIP W/CBL SM
|
Facility
|
IP
|
$8,536.68
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,561.00 |
| Max. Negotiated Rate |
$8,195.21 |
| Rate for Payer: Aetna Commercial |
$6,573.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,658.61
|
| Rate for Payer: Cash Price |
$4,268.34
|
| Rate for Payer: Cigna Commercial |
$7,085.44
|
| Rate for Payer: First Health Commercial |
$8,109.85
|
| Rate for Payer: Humana Commercial |
$7,256.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,000.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,300.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,512.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,402.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,829.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,426.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,890.31
|
| Rate for Payer: PHCS Commercial |
$8,195.21
|
| Rate for Payer: United Healthcare All Payer |
$7,512.28
|
|
|
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 |
$15.55 |
| 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 |
$15.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,563.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.99
|
| 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 |
$15.55
|
| 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 |
$18.66
|
| 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 |
$7,272.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,757.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,435.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,690.42
|
| 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 |
$2,908.88 |
| 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 |
$7,272.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,757.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,435.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,690.42
|
| 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 |
$107.29 |
| 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 |
$286.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$311.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.77
|
| 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 |
$107.29 |
| 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 |
$286.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$311.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.77
|
| 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 |
$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
|
|
|
DANTRIUM (DANTROLENE 25MG/1CAP
|
Facility
|
OP
|
$9.63
|
|
|
Service Code
|
NDC 68084030021
|
| Hospital Charge Code |
25000513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.89 |
| 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 |
$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
|
|
|
DANTROLENE 250mg SDV
|
Facility
|
IP
|
$5,064.36
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004276
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1,519.31 |
| Max. Negotiated Rate |
$4,861.79 |
| Rate for Payer: Aetna Commercial |
$3,899.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,950.20
|
| Rate for Payer: Cash Price |
$2,532.18
|
| Rate for Payer: Cigna Commercial |
$4,203.42
|
| Rate for Payer: First Health Commercial |
$4,811.14
|
| Rate for Payer: Humana Commercial |
$4,304.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,152.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,737.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,519.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,456.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,798.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,051.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,405.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,494.41
|
| Rate for Payer: PHCS Commercial |
$4,861.79
|
| Rate for Payer: United Healthcare All Payer |
$4,456.64
|
|
|
DANTROLENE 250mg SDV
|
Facility
|
OP
|
$5,064.36
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004276
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1,519.31 |
| Max. Negotiated Rate |
$4,861.79 |
| Rate for Payer: Aetna Commercial |
$3,899.56
|
| Rate for Payer: Anthem Medicaid |
$1,741.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,950.20
|
| Rate for Payer: Cash Price |
$2,532.18
|
| Rate for Payer: Cigna Commercial |
$4,203.42
|
| Rate for Payer: First Health Commercial |
$4,811.14
|
| Rate for Payer: Humana Commercial |
$4,304.71
|
| Rate for Payer: Humana KY Medicaid |
$1,741.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1,759.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,152.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,737.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,519.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,776.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,456.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,798.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,051.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,405.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,494.41
|
| Rate for Payer: PHCS Commercial |
$4,861.79
|
| Rate for Payer: United Healthcare All Payer |
$4,456.64
|
|
|
DAPAKENE 500/10ML ORAL SUSP
|
Facility
|
OP
|
$10.24
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.07 |
| 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 |
$8.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.07
|
| 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 |
$3.07 |
| 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 |
$8.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.07
|
| Rate for Payer: PHCS Commercial |
$9.83
|
| Rate for Payer: United Healthcare All Payer |
$9.01
|
|
|
DAPSONE 100MG TABLET
|
Facility
|
OP
|
$10.42
|
|
|
Service Code
|
NDC 29033003730
|
| Hospital Charge Code |
25000515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.13 |
| 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 |
$8.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.19
|
| Rate for Payer: PHCS Commercial |
$10.00
|
| Rate for Payer: United Healthcare All Payer |
$9.17
|
|
|
DAPSONE 100MG TABLET
|
Facility
|
IP
|
$10.42
|
|
|
Service Code
|
NDC 29033003730
|
| Hospital Charge Code |
25000515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.13 |
| 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 |
$8.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.19
|
| 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 |
$3.01 |
| 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 |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| 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 |
$3.01 |
| 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 |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
DARZALEX 100MG/5ML VIAL
|
Facility
|
OP
|
$4,227.18
|
|
|
Service Code
|
HCPCS J9145
|
| Hospital Charge Code |
25002597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.84 |
| Max. Negotiated Rate |
$4,058.09 |
| Rate for Payer: Aetna Commercial |
$3,254.93
|
| Rate for Payer: Anthem Medicaid |
$1,453.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$69.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,297.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$97.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.28
|
| Rate for Payer: Cash Price |
$2,113.59
|
| Rate for Payer: Cash Price |
$2,113.59
|
| Rate for Payer: Cigna Commercial |
$3,508.56
|
| Rate for Payer: First Health Commercial |
$4,015.82
|
| Rate for Payer: Humana Commercial |
$3,593.10
|
| Rate for Payer: Humana KY Medicaid |
$1,453.73
|
| Rate for Payer: Humana Medicare Advantage |
$69.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,468.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,466.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,119.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,482.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,719.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,170.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,381.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,677.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,916.75
|
| Rate for Payer: PHCS Commercial |
$4,058.09
|
| Rate for Payer: United Healthcare All Payer |
$3,719.92
|
|
|
DARZALEX 100MG/5ML VIAL
|
Facility
|
IP
|
$4,227.18
|
|
|
Service Code
|
HCPCS J9145
|
| Hospital Charge Code |
25002597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,268.15 |
| Max. Negotiated Rate |
$4,058.09 |
| Rate for Payer: Aetna Commercial |
$3,254.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,297.20
|
| Rate for Payer: Cash Price |
$2,113.59
|
| Rate for Payer: Cigna Commercial |
$3,508.56
|
| Rate for Payer: First Health Commercial |
$4,015.82
|
| Rate for Payer: Humana Commercial |
$3,593.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,466.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,119.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,268.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,719.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,170.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,381.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,677.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,916.75
|
| Rate for Payer: PHCS Commercial |
$4,058.09
|
| Rate for Payer: United Healthcare All Payer |
$3,719.92
|
|
|
DARZALEX 400MG/20ML VIAL
|
Facility
|
IP
|
$16,030.09
|
|
|
Service Code
|
HCPCS J9145
|
| Hospital Charge Code |
25002598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,809.03 |
| Max. Negotiated Rate |
$15,388.89 |
| Rate for Payer: Aetna Commercial |
$12,343.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,503.47
|
| Rate for Payer: Cash Price |
$8,015.04
|
| Rate for Payer: Cigna Commercial |
$13,304.97
|
| Rate for Payer: First Health Commercial |
$15,228.59
|
| Rate for Payer: Humana Commercial |
$13,625.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,144.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,830.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,809.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,106.48
|
| Rate for Payer: Ohio Health Group HMO |
$12,022.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,824.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,946.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,060.76
|
| Rate for Payer: PHCS Commercial |
$15,388.89
|
| Rate for Payer: United Healthcare All Payer |
$14,106.48
|
|
|
DARZALEX 400MG/20ML VIAL
|
Facility
|
OP
|
$16,030.09
|
|
|
Service Code
|
HCPCS J9145
|
| Hospital Charge Code |
25002598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.84 |
| Max. Negotiated Rate |
$15,388.89 |
| Rate for Payer: Aetna Commercial |
$12,343.17
|
| Rate for Payer: Anthem Medicaid |
$5,512.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$69.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,503.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$97.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.28
|
| Rate for Payer: Cash Price |
$8,015.04
|
| Rate for Payer: Cash Price |
$8,015.04
|
| Rate for Payer: Cigna Commercial |
$13,304.97
|
| Rate for Payer: First Health Commercial |
$15,228.59
|
| Rate for Payer: Humana Commercial |
$13,625.58
|
| Rate for Payer: Humana KY Medicaid |
$5,512.75
|
| Rate for Payer: Humana Medicare Advantage |
$69.84
|
| Rate for Payer: Kentucky WC Medicaid |
$5,568.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,144.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,830.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,623.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,106.48
|
| Rate for Payer: Ohio Health Group HMO |
$12,022.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,824.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,946.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,060.76
|
| Rate for Payer: PHCS Commercial |
$15,388.89
|
| Rate for Payer: United Healthcare All Payer |
$14,106.48
|
|
|
DARZALEX FASPRO 10mg (1800mg)
|
Facility
|
OP
|
$57,616.69
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
25004160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.67 |
| Max. Negotiated Rate |
$55,312.02 |
| Rate for Payer: Aetna Commercial |
$44,364.85
|
| Rate for Payer: Anthem Medicaid |
$19,814.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44,941.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.80
|
| Rate for Payer: Cash Price |
$28,808.35
|
| Rate for Payer: Cash Price |
$28,808.35
|
| Rate for Payer: Cigna Commercial |
$47,821.85
|
| Rate for Payer: First Health Commercial |
$54,735.86
|
| Rate for Payer: Humana Commercial |
$48,974.19
|
| Rate for Payer: Humana KY Medicaid |
$19,814.38
|
| Rate for Payer: Humana Medicare Advantage |
$54.67
|
| Rate for Payer: Kentucky WC Medicaid |
$20,016.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$47,245.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42,521.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,211.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$50,702.69
|
| Rate for Payer: Ohio Health Group HMO |
$43,212.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46,093.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50,126.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39,755.52
|
| Rate for Payer: PHCS Commercial |
$55,312.02
|
| Rate for Payer: United Healthcare All Payer |
$50,702.69
|
|
|
DARZALEX FASPRO 10mg (1800mg)
|
Facility
|
IP
|
$57,616.69
|
|
|
Service Code
|
HCPCS J9144
|
| Hospital Charge Code |
25004160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17,285.01 |
| Max. Negotiated Rate |
$55,312.02 |
| Rate for Payer: Aetna Commercial |
$44,364.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44,941.02
|
| Rate for Payer: Cash Price |
$28,808.35
|
| Rate for Payer: Cigna Commercial |
$47,821.85
|
| Rate for Payer: First Health Commercial |
$54,735.86
|
| Rate for Payer: Humana Commercial |
$48,974.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$47,245.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42,521.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,285.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$50,702.69
|
| Rate for Payer: Ohio Health Group HMO |
$43,212.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46,093.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50,126.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39,755.52
|
| Rate for Payer: PHCS Commercial |
$55,312.02
|
| Rate for Payer: United Healthcare All Payer |
$50,702.69
|
|
|
DAUNORUBICIN 10MG (20MG VIAL)
|
Facility
|
IP
|
$714.71
|
|
|
Service Code
|
HCPCS J9150
|
| Hospital Charge Code |
25002599
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.41 |
| Max. Negotiated Rate |
$686.12 |
| Rate for Payer: Aetna Commercial |
$550.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$557.47
|
| Rate for Payer: Cash Price |
$357.36
|
| Rate for Payer: Cigna Commercial |
$593.21
|
| Rate for Payer: First Health Commercial |
$678.97
|
| Rate for Payer: Humana Commercial |
$607.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$586.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$527.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$214.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$628.94
|
| Rate for Payer: Ohio Health Group HMO |
$536.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$571.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$621.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$493.15
|
| Rate for Payer: PHCS Commercial |
$686.12
|
| Rate for Payer: United Healthcare All Payer |
$628.94
|
|
