|
DIFICID 200MG TABLET
|
Facility
|
IP
|
$430.25
|
|
|
Service Code
|
NDC 52015008001
|
| Hospital Charge Code |
25000558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.07 |
| Max. Negotiated Rate |
$413.04 |
| Rate for Payer: Aetna Commercial |
$331.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.60
|
| Rate for Payer: Cash Price |
$215.12
|
| Rate for Payer: Cigna Commercial |
$357.11
|
| Rate for Payer: First Health Commercial |
$408.74
|
| Rate for Payer: Humana Commercial |
$365.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.62
|
| Rate for Payer: Ohio Health Group HMO |
$322.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$374.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.87
|
| Rate for Payer: PHCS Commercial |
$413.04
|
| Rate for Payer: United Healthcare All Payer |
$378.62
|
|
|
DIFLUCAN 200MG/100ML BOTTLE
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
25002063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
DIFLUCAN 200MG/100ML BOTTLE
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
25002063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
DIFLUCAN (FLUCONAZO 100MG/1TAB
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 68001025204
|
| Hospital Charge Code |
25000559
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem Medicaid |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Humana KY Medicaid |
$3.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
DIFLUCAN (FLUCONAZO 100MG/1TAB
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 68001025204
|
| Hospital Charge Code |
25000559
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Aetna Commercial |
$7.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.03
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.12
|
| Rate for Payer: United Healthcare All Payer |
$8.36
|
|
|
DIFLUCAN (FLUCONAZOLE) 200MG T
|
Facility
|
OP
|
$4.87
|
|
|
Service Code
|
NDC 57237000630
|
| Hospital Charge Code |
25000560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DIFLUCAN (FLUCONAZOLE) 200MG T
|
Facility
|
IP
|
$4.87
|
|
|
Service Code
|
NDC 57237000630
|
| Hospital Charge Code |
25000560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
DIFLUCAN(FLUCONAZOLE) 50MG TAB
|
Facility
|
OP
|
$9.12
|
|
|
Service Code
|
NDC 68001025104
|
| Hospital Charge Code |
25000562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Anthem Medicaid |
$3.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.57
|
| Rate for Payer: First Health Commercial |
$8.66
|
| Rate for Payer: Humana Commercial |
$7.75
|
| Rate for Payer: Humana KY Medicaid |
$3.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
DIFLUCAN(FLUCONAZOLE) 50MG TAB
|
Facility
|
IP
|
$9.12
|
|
|
Service Code
|
NDC 68001025104
|
| Hospital Charge Code |
25000562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.57
|
| Rate for Payer: First Health Commercial |
$8.66
|
| Rate for Payer: Humana Commercial |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
DIGIAL PROSTATE EXAM
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS G0102
|
| Hospital Charge Code |
51000132
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna Commercial |
$23.10
|
| Rate for Payer: Anthem Medicaid |
$10.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$24.90
|
| Rate for Payer: First Health Commercial |
$28.50
|
| Rate for Payer: Humana Commercial |
$25.50
|
| Rate for Payer: Humana KY Medicaid |
$10.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.40
|
| Rate for Payer: Ohio Health Group HMO |
$22.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.70
|
| Rate for Payer: PHCS Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Payer |
$26.40
|
|
|
DIGIAL PROSTATE EXAM
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS G0102
|
| Hospital Charge Code |
51000132
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Ambetter Exchange |
$8.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.86
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.22
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$10.69
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.22
|
|
|
DIGIAL PROSTATE EXAM
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS G0102
|
| Hospital Charge Code |
51000132
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna Commercial |
$23.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$24.90
|
| Rate for Payer: First Health Commercial |
$28.50
|
| Rate for Payer: Humana Commercial |
$25.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.40
|
| Rate for Payer: Ohio Health Group HMO |
$22.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.70
|
| Rate for Payer: PHCS Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Payer |
$26.40
|
|
|
DIGIFAB [1 VIAL] 40MG VIAL
|
Facility
|
IP
|
$6,724.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
25002021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,017.20 |
| Max. Negotiated Rate |
$6,455.04 |
| Rate for Payer: Aetna Commercial |
$5,177.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,244.72
|
| Rate for Payer: Cash Price |
$3,362.00
|
| Rate for Payer: Cigna Commercial |
$5,580.92
|
| Rate for Payer: First Health Commercial |
$6,387.80
|
| Rate for Payer: Humana Commercial |
$5,715.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,513.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,849.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,639.56
|
| Rate for Payer: PHCS Commercial |
$6,455.04
|
| Rate for Payer: United Healthcare All Payer |
$5,917.12
|
|
|
DIGIFAB [1 VIAL] 40MG VIAL
|
Facility
|
OP
|
$6,724.00
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
25002021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,312.38 |
| Max. Negotiated Rate |
$6,956.01 |
| Rate for Payer: Aetna Commercial |
$5,177.48
|
| Rate for Payer: Anthem Medicaid |
$2,312.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,968.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,244.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,956.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,707.58
|
| Rate for Payer: Cash Price |
$3,362.00
|
| Rate for Payer: Cash Price |
$3,362.00
|
| Rate for Payer: Cigna Commercial |
$5,580.92
|
| Rate for Payer: First Health Commercial |
$6,387.80
|
| Rate for Payer: Humana Commercial |
$5,715.40
|
| Rate for Payer: Humana KY Medicaid |
$2,312.38
|
| Rate for Payer: Humana Medicare Advantage |
$4,968.58
|
| Rate for Payer: Kentucky WC Medicaid |
$2,335.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,513.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,962.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,358.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,849.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,639.56
|
| Rate for Payer: PHCS Commercial |
$6,455.04
|
| Rate for Payer: United Healthcare All Payer |
$5,917.12
|
|
|
DIGOXIN
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS 80162
|
| Hospital Charge Code |
30000025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$75.84 |
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Anthem Medicaid |
$13.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.28
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Humana KY Medicaid |
$13.28
|
| Rate for Payer: Humana Medicare Advantage |
$13.28
|
| Rate for Payer: Kentucky WC Medicaid |
$13.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.51
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
|
|
DIGOXIN
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS 80162
|
| Hospital Charge Code |
30000025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.70 |
| Max. Negotiated Rate |
$75.84 |
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.44
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.51
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
|
|
DILANTIN 100 MG CAP DAW
|
Facility
|
IP
|
$9.91
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
25000567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$7.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.73
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna Commercial |
$8.23
|
| Rate for Payer: First Health Commercial |
$9.41
|
| Rate for Payer: Humana Commercial |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.72
|
| Rate for Payer: Ohio Health Group HMO |
$7.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.84
|
| Rate for Payer: PHCS Commercial |
$9.51
|
| Rate for Payer: United Healthcare All Payer |
$8.72
|
|
|
DILANTIN 100 MG CAP DAW
|
Facility
|
OP
|
$9.91
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
25000567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$7.63
|
| Rate for Payer: Anthem Medicaid |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.73
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Cigna Commercial |
$8.23
|
| Rate for Payer: First Health Commercial |
$9.41
|
| Rate for Payer: Humana Commercial |
$8.42
|
| Rate for Payer: Humana KY Medicaid |
$3.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.72
|
| Rate for Payer: Ohio Health Group HMO |
$7.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.84
|
| Rate for Payer: PHCS Commercial |
$9.51
|
| Rate for Payer: United Healthcare All Payer |
$8.72
|
|
|
DILANTIN 50 MG (100MG/2ML)
|
Facility
|
OP
|
$77.39
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.22 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$59.59
|
| Rate for Payer: Anthem Medicaid |
$26.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.36
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$64.23
|
| Rate for Payer: First Health Commercial |
$73.52
|
| Rate for Payer: Humana Commercial |
$65.78
|
| Rate for Payer: Humana KY Medicaid |
$26.61
|
| Rate for Payer: Kentucky WC Medicaid |
$26.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.10
|
| Rate for Payer: Ohio Health Group HMO |
$58.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.40
|
| Rate for Payer: PHCS Commercial |
$74.29
|
| Rate for Payer: United Healthcare All Payer |
$68.10
|
|
|
DILANTIN 50 MG (100MG/2ML)
|
Facility
|
IP
|
$77.39
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.22 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$59.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.36
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$64.23
|
| Rate for Payer: First Health Commercial |
$73.52
|
| Rate for Payer: Humana Commercial |
$65.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.10
|
| Rate for Payer: Ohio Health Group HMO |
$58.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.40
|
| Rate for Payer: PHCS Commercial |
$74.29
|
| Rate for Payer: United Healthcare All Payer |
$68.10
|
|
|
DILANTIN 50MG/ML (250MG/5MLVL)
|
Facility
|
OP
|
$77.99
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$74.87 |
| Rate for Payer: Aetna Commercial |
$60.05
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.83
|
| Rate for Payer: Cash Price |
$38.99
|
| Rate for Payer: Cigna Commercial |
$64.73
|
| Rate for Payer: First Health Commercial |
$74.09
|
| Rate for Payer: Humana Commercial |
$66.29
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Kentucky WC Medicaid |
$27.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.63
|
| Rate for Payer: Ohio Health Group HMO |
$58.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.81
|
| Rate for Payer: PHCS Commercial |
$74.87
|
| Rate for Payer: United Healthcare All Payer |
$68.63
|
|
|
DILANTIN 50MG/ML (250MG/5MLVL)
|
Facility
|
IP
|
$77.99
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$74.87 |
| Rate for Payer: Aetna Commercial |
$60.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.83
|
| Rate for Payer: Cash Price |
$38.99
|
| Rate for Payer: Cigna Commercial |
$64.73
|
| Rate for Payer: First Health Commercial |
$74.09
|
| Rate for Payer: Humana Commercial |
$66.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.63
|
| Rate for Payer: Ohio Health Group HMO |
$58.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.81
|
| Rate for Payer: PHCS Commercial |
$74.87
|
| Rate for Payer: United Healthcare All Payer |
$68.63
|
|
|
DILANTIN (PHENYTOIN) 100MG/4ML
|
Facility
|
OP
|
$9.27
|
|
|
Service Code
|
NDC 66689077508
|
| Hospital Charge Code |
25000564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Anthem Medicaid |
$3.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.81
|
| Rate for Payer: Humana Commercial |
$7.88
|
| Rate for Payer: Humana KY Medicaid |
$3.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.16
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.40
|
| Rate for Payer: PHCS Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Payer |
$8.16
|
|
|
DILANTIN (PHENYTOIN) 100MG/4ML
|
Facility
|
IP
|
$9.27
|
|
|
Service Code
|
NDC 66689077508
|
| Hospital Charge Code |
25000564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.81
|
| Rate for Payer: Humana Commercial |
$7.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.16
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.40
|
| Rate for Payer: PHCS Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Payer |
$8.16
|
|
|
DILANTIN (PHENYTOIN) 30MG/1CAP
|
Facility
|
IP
|
$9.49
|
|
|
Service Code
|
NDC 71374066
|
| Hospital Charge Code |
25000565
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna Commercial |
$7.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.35
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.11
|
| Rate for Payer: United Healthcare All Payer |
$8.35
|
|
