|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
IP
|
$5,087.50
|
|
|
Service Code
|
HCPCS 53605
|
| Hospital Charge Code |
761T2118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,526.25 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,426.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,510.38
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
HCPCS 53605
|
| Hospital Charge Code |
761P2118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.11 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$107.61
|
| Rate for Payer: Ambetter Exchange |
$60.30
|
| Rate for Payer: Anthem Medicaid |
$51.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$60.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$72.36
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$97.27
|
| Rate for Payer: Healthspan PPO |
$86.04
|
| Rate for Payer: Humana Medicaid |
$51.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$60.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.13
|
| Rate for Payer: Molina Healthcare Passport |
$51.11
|
| Rate for Payer: Multiplan PHCS |
$159.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.39
|
| Rate for Payer: UHCCP Medicaid |
$92.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$60.30
|
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
OP
|
$5,352.50
|
|
|
Service Code
|
HCPCS 53605
|
| Hospital Charge Code |
76102118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,840.72 |
| Max. Negotiated Rate |
$5,138.40 |
| Rate for Payer: Aetna Commercial |
$4,121.43
|
| Rate for Payer: Anthem Medicaid |
$1,840.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,174.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Cash Price |
$2,676.25
|
| Rate for Payer: Cash Price |
$2,676.25
|
| Rate for Payer: Cigna Commercial |
$4,442.57
|
| Rate for Payer: First Health Commercial |
$5,084.88
|
| Rate for Payer: Humana Commercial |
$4,549.62
|
| Rate for Payer: Humana KY Medicaid |
$1,840.72
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,859.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,389.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,950.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,877.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,710.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,014.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,282.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,656.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,693.22
|
| Rate for Payer: PHCS Commercial |
$5,138.40
|
| Rate for Payer: United Healthcare All Payer |
$4,710.20
|
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Professional
|
Both
|
$5,352.50
|
|
|
Service Code
|
HCPCS 53605
|
| Hospital Charge Code |
76102118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.11 |
| Max. Negotiated Rate |
$3,211.50 |
| Rate for Payer: Aetna Commercial |
$107.61
|
| Rate for Payer: Ambetter Exchange |
$60.30
|
| Rate for Payer: Anthem Medicaid |
$51.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$60.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$72.36
|
| Rate for Payer: Cash Price |
$2,676.25
|
| Rate for Payer: Cash Price |
$2,676.25
|
| Rate for Payer: Cigna Commercial |
$97.27
|
| Rate for Payer: Healthspan PPO |
$86.04
|
| Rate for Payer: Humana Medicaid |
$51.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$60.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.13
|
| Rate for Payer: Molina Healthcare Passport |
$51.11
|
| Rate for Payer: Multiplan PHCS |
$3,211.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.39
|
| Rate for Payer: UHCCP Medicaid |
$1,873.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$60.30
|
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Professional
|
Both
|
$2,472.47
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
76102119
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.47 |
| Max. Negotiated Rate |
$1,483.48 |
| Rate for Payer: Aetna Commercial |
$144.71
|
| Rate for Payer: Ambetter Exchange |
$82.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$55.47
|
| Rate for Payer: Anthem Medicaid |
$61.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$82.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$82.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.48
|
| Rate for Payer: Cash Price |
$1,236.23
|
| Rate for Payer: Cash Price |
$1,236.23
|
| Rate for Payer: Cigna Commercial |
$198.31
|
| Rate for Payer: Healthspan PPO |
$158.08
|
| Rate for Payer: Humana Medicaid |
$61.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$82.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.59
|
| Rate for Payer: Molina Healthcare Passport |
$61.36
|
| Rate for Payer: Multiplan PHCS |
$1,483.48
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$106.69
|
| Rate for Payer: UHCCP Medicaid |
$58.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$82.07
|
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
OP
|
$1,972.47
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
761T2119
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$1,893.57 |
| Rate for Payer: Aetna Commercial |
$1,518.80
|
| Rate for Payer: Anthem Medicaid |
$678.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,538.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$986.24
|
| Rate for Payer: Cash Price |
$986.24
|
| Rate for Payer: Cigna Commercial |
$1,637.15
|
| Rate for Payer: First Health Commercial |
$1,873.85
|
| Rate for Payer: Humana Commercial |
$1,676.60
|
| Rate for Payer: Humana KY Medicaid |
$678.33
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$685.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,617.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,455.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$691.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,735.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,479.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,577.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,716.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,361.00
|
| Rate for Payer: PHCS Commercial |
$1,893.57
|
| Rate for Payer: United Healthcare All Payer |
$1,735.77
|
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
IP
|
$1,972.47
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
761T2119
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$591.74 |
| Max. Negotiated Rate |
$1,893.57 |
| Rate for Payer: Aetna Commercial |
$1,518.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,538.53
|
| Rate for Payer: Cash Price |
$986.24
|
| Rate for Payer: Cigna Commercial |
$1,637.15
|
| Rate for Payer: First Health Commercial |
$1,873.85
|
| Rate for Payer: Humana Commercial |
$1,676.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,617.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,455.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$591.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,735.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,479.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,577.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,716.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,361.00
|
| Rate for Payer: PHCS Commercial |
$1,893.57
|
| Rate for Payer: United Healthcare All Payer |
$1,735.77
|
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
IP
|
$2,472.47
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
76102119
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$741.74 |
| Max. Negotiated Rate |
$2,373.57 |
| Rate for Payer: Aetna Commercial |
$1,903.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,928.53
|
| Rate for Payer: Cash Price |
$1,236.23
|
| Rate for Payer: Cigna Commercial |
$2,052.15
|
| Rate for Payer: First Health Commercial |
$2,348.85
|
| Rate for Payer: Humana Commercial |
$2,101.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,027.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,824.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$741.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,175.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,854.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,977.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,151.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,706.00
|
| Rate for Payer: PHCS Commercial |
$2,373.57
|
| Rate for Payer: United Healthcare All Payer |
$2,175.77
|
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Facility
|
OP
|
$2,472.47
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
76102119
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$2,373.57 |
| Rate for Payer: Aetna Commercial |
$1,903.80
|
| Rate for Payer: Anthem Medicaid |
$850.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,928.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$1,236.23
|
| Rate for Payer: Cash Price |
$1,236.23
|
| Rate for Payer: Cigna Commercial |
$2,052.15
|
| Rate for Payer: First Health Commercial |
$2,348.85
|
| Rate for Payer: Humana Commercial |
$2,101.60
|
| Rate for Payer: Humana KY Medicaid |
$850.28
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$858.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,027.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,824.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$867.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,175.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,854.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,977.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,151.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,706.00
|
| Rate for Payer: PHCS Commercial |
$2,373.57
|
| Rate for Payer: United Healthcare All Payer |
$2,175.77
|
|
|
DIL URET STRIX FILI/FOL MALE 1
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
761P2119
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.47 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$144.71
|
| Rate for Payer: Ambetter Exchange |
$82.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$55.47
|
| Rate for Payer: Anthem Medicaid |
$61.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$82.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$82.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.48
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$198.31
|
| Rate for Payer: Healthspan PPO |
$158.08
|
| Rate for Payer: Humana Medicaid |
$61.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$82.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.59
|
| Rate for Payer: Molina Healthcare Passport |
$61.36
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$106.69
|
| Rate for Payer: UHCCP Medicaid |
$58.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$82.07
|
|
|
DIMETHICONE 12.5% CREAM 118mL
|
Facility
|
IP
|
$3.42
|
|
|
Service Code
|
NDC 53329002144
|
| Hospital Charge Code |
25004442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna Commercial |
$2.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.67
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna Commercial |
$2.84
|
| Rate for Payer: First Health Commercial |
$3.25
|
| Rate for Payer: Humana Commercial |
$2.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.01
|
| Rate for Payer: Ohio Health Group HMO |
$2.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.36
|
| Rate for Payer: PHCS Commercial |
$3.28
|
| Rate for Payer: United Healthcare All Payer |
$3.01
|
|
|
DIMETHICONE 12.5% CREAM 118mL
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 53329002144
|
| Hospital Charge Code |
25004442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna Commercial |
$2.63
|
| Rate for Payer: Anthem Medicaid |
$1.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.67
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna Commercial |
$2.84
|
| Rate for Payer: First Health Commercial |
$3.25
|
| Rate for Payer: Humana Commercial |
$2.91
|
| Rate for Payer: Humana KY Medicaid |
$1.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.01
|
| Rate for Payer: Ohio Health Group HMO |
$2.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.36
|
| Rate for Payer: PHCS Commercial |
$3.28
|
| Rate for Payer: United Healthcare All Payer |
$3.01
|
|
|
DIOVAN 40 MG TABLET
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 378580793
|
| Hospital Charge Code |
25000568
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
DIOVAN 40 MG TABLET
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 378580793
|
| Hospital Charge Code |
25000568
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
DIOVAN 80MG TABLET
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 378581377
|
| Hospital Charge Code |
25000569
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
DIOVAN 80MG TABLET
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 378581377
|
| Hospital Charge Code |
25000569
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
Diphenhydramine 1% Crm 28gm
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
25000314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.10
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.11
|
| Rate for Payer: First Health Commercial |
$0.12
|
| Rate for Payer: Humana Commercial |
$0.11
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.09
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
Diphenhydramine 1% Crm 28gm
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
25000314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.11
|
| Rate for Payer: First Health Commercial |
$0.12
|
| Rate for Payer: Humana Commercial |
$0.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.09
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
Diphenhydramine 2% Crm 28gm
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 24385021003
|
| Hospital Charge Code |
25000313
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
Diphenhydramine 2% Crm 28gm
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 24385021003
|
| Hospital Charge Code |
25000313
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
DIPRIVAN 10MG [200MG/20ML VL]
|
Facility
|
OP
|
$112.84
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
25002328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$108.33 |
| Rate for Payer: Aetna Commercial |
$86.89
|
| Rate for Payer: Aetna Commercial |
$93.63
|
| Rate for Payer: Anthem Medicaid |
$38.81
|
| Rate for Payer: Anthem Medicaid |
$41.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.85
|
| Rate for Payer: Cash Price |
$56.42
|
| Rate for Payer: Cash Price |
$60.80
|
| Rate for Payer: Cigna Commercial |
$100.93
|
| Rate for Payer: Cigna Commercial |
$93.66
|
| Rate for Payer: First Health Commercial |
$115.52
|
| Rate for Payer: First Health Commercial |
$107.20
|
| Rate for Payer: Humana Commercial |
$95.91
|
| Rate for Payer: Humana Commercial |
$103.36
|
| Rate for Payer: Humana KY Medicaid |
$38.81
|
| Rate for Payer: Humana KY Medicaid |
$41.82
|
| Rate for Payer: Kentucky WC Medicaid |
$42.24
|
| Rate for Payer: Kentucky WC Medicaid |
$39.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.01
|
| Rate for Payer: Ohio Health Group HMO |
$84.63
|
| Rate for Payer: Ohio Health Group HMO |
$91.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.90
|
| Rate for Payer: PHCS Commercial |
$116.74
|
| Rate for Payer: PHCS Commercial |
$108.33
|
| Rate for Payer: United Healthcare All Payer |
$107.01
|
| Rate for Payer: United Healthcare All Payer |
$99.30
|
|
|
DIPRIVAN 10MG [200MG/20ML VL]
|
Facility
|
IP
|
$112.84
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
25002328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$108.33 |
| Rate for Payer: Aetna Commercial |
$86.89
|
| Rate for Payer: Aetna Commercial |
$93.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.85
|
| Rate for Payer: Cash Price |
$56.42
|
| Rate for Payer: Cash Price |
$60.80
|
| Rate for Payer: Cigna Commercial |
$93.66
|
| Rate for Payer: Cigna Commercial |
$100.93
|
| Rate for Payer: First Health Commercial |
$115.52
|
| Rate for Payer: First Health Commercial |
$107.20
|
| Rate for Payer: Humana Commercial |
$103.36
|
| Rate for Payer: Humana Commercial |
$95.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.01
|
| Rate for Payer: Ohio Health Group HMO |
$84.63
|
| Rate for Payer: Ohio Health Group HMO |
$91.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.86
|
| Rate for Payer: PHCS Commercial |
$108.33
|
| Rate for Payer: PHCS Commercial |
$116.74
|
| Rate for Payer: United Healthcare All Payer |
$99.30
|
| Rate for Payer: United Healthcare All Payer |
$107.01
|
|
|
DIPRIVAN 10MG (500MG/50MLV)
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
25002327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.60 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.18
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
DIPRIVAN 10MG (500MG/50MLV)
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
25002327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.60 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem Medicaid |
$41.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Humana KY Medicaid |
$41.96
|
| Rate for Payer: Kentucky WC Medicaid |
$42.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.18
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
DIPRIVAN 10MG/ML (1000MGV)
|
Facility
|
IP
|
$185.21
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
25002326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.56 |
| Max. Negotiated Rate |
$177.80 |
| Rate for Payer: Aetna Commercial |
$142.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.46
|
| Rate for Payer: Cash Price |
$92.61
|
| Rate for Payer: Cigna Commercial |
$153.72
|
| Rate for Payer: First Health Commercial |
$175.95
|
| Rate for Payer: Humana Commercial |
$157.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.98
|
| Rate for Payer: Ohio Health Group HMO |
$138.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.79
|
| Rate for Payer: PHCS Commercial |
$177.80
|
| Rate for Payer: United Healthcare All Payer |
$162.98
|
|
