|
KENALOG(TRIAMCINOLONE)IN O 5GM
|
Facility
|
IP
|
$9.98
|
|
|
Service Code
|
NDC 64980032005
|
| Hospital Charge Code |
25000817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$7.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.78
|
| Rate for Payer: Cash Price |
$4.99
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: First Health Commercial |
$9.48
|
| Rate for Payer: Humana Commercial |
$8.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.78
|
| Rate for Payer: Ohio Health Group HMO |
$7.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.09
|
| Rate for Payer: PHCS Commercial |
$9.58
|
| Rate for Payer: United Healthcare All Payer |
$8.78
|
|
|
KEPPRA 10MG [500MG/5ML VIAL]
|
Facility
|
OP
|
$79.89
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25002208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$76.69 |
| Rate for Payer: Aetna Commercial |
$61.52
|
| Rate for Payer: Anthem Medicaid |
$27.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.31
|
| Rate for Payer: Cash Price |
$39.94
|
| Rate for Payer: Cigna Commercial |
$66.31
|
| Rate for Payer: First Health Commercial |
$75.90
|
| Rate for Payer: Humana Commercial |
$67.91
|
| Rate for Payer: Humana KY Medicaid |
$27.47
|
| Rate for Payer: Kentucky WC Medicaid |
$27.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.30
|
| Rate for Payer: Ohio Health Group HMO |
$59.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.77
|
| Rate for Payer: PHCS Commercial |
$76.69
|
| Rate for Payer: United Healthcare All Payer |
$70.30
|
|
|
KEPPRA 10MG [500MG/5ML VIAL]
|
Facility
|
IP
|
$79.89
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25002208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$76.69 |
| Rate for Payer: Aetna Commercial |
$61.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.31
|
| Rate for Payer: Cash Price |
$39.94
|
| Rate for Payer: Cigna Commercial |
$66.31
|
| Rate for Payer: First Health Commercial |
$75.90
|
| Rate for Payer: Humana Commercial |
$67.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.30
|
| Rate for Payer: Ohio Health Group HMO |
$59.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.77
|
| Rate for Payer: PHCS Commercial |
$76.69
|
| Rate for Payer: United Healthcare All Payer |
$70.30
|
|
|
KEPPRA(LEVETIRACETAM)250MG TAB
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
25000821
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
KEPPRA(LEVETIRACETAM)250MG TAB
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
25000821
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
KEPPRA(LEVETIRACETM)500 MG TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
25000822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| 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 |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
KEPPRA(LEVETIRACETM)500 MG TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
25000822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| 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 |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
KEPPRA (PREMIX)1000MG/100ML IV
|
Facility
|
IP
|
$117.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25002207
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.23 |
| Max. Negotiated Rate |
$112.49 |
| Rate for Payer: Aetna Commercial |
$90.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.40
|
| Rate for Payer: Cash Price |
$58.59
|
| Rate for Payer: Cigna Commercial |
$97.26
|
| Rate for Payer: First Health Commercial |
$111.32
|
| Rate for Payer: Humana Commercial |
$99.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.12
|
| Rate for Payer: Ohio Health Group HMO |
$87.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.33
|
| Rate for Payer: PHCS Commercial |
$112.49
|
| Rate for Payer: United Healthcare All Payer |
$103.12
|
|
|
KEPPRA (PREMIX)1000MG/100ML IV
|
Facility
|
OP
|
$117.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25002207
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.23 |
| Max. Negotiated Rate |
$112.49 |
| Rate for Payer: Aetna Commercial |
$90.23
|
| Rate for Payer: Anthem Medicaid |
$40.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.40
|
| Rate for Payer: Cash Price |
$58.59
|
| Rate for Payer: Cigna Commercial |
$97.26
|
| Rate for Payer: First Health Commercial |
$111.32
|
| Rate for Payer: Humana Commercial |
$99.60
|
| Rate for Payer: Humana KY Medicaid |
$40.30
|
| Rate for Payer: Kentucky WC Medicaid |
$40.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.12
|
| Rate for Payer: Ohio Health Group HMO |
$87.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.33
|
| Rate for Payer: PHCS Commercial |
$112.49
|
| Rate for Payer: United Healthcare All Payer |
$103.12
|
|
|
KEPPRA SF 100MG/ML 5ML SOL
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
25000818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.45
|
| Rate for Payer: Humana Commercial |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.12
|
| Rate for Payer: Ohio Health Group HMO |
$3.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
KEPPRA SF 100MG/ML 5ML SOL
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
25000818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.45
|
| Rate for Payer: Humana Commercial |
$3.98
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.12
|
| Rate for Payer: Ohio Health Group HMO |
$3.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
| Rate for Payer: Aetna Commercial |
$3.60
|
|
|
KEPPRA XR 500MG TABLET
|
Facility
|
OP
|
$4.72
|
|
|
Service Code
|
NDC 68001011306
|
| Hospital Charge Code |
25000819
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.92
|
| Rate for Payer: First Health Commercial |
$4.48
|
| Rate for Payer: Humana Commercial |
$4.01
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.15
|
| Rate for Payer: Ohio Health Group HMO |
$3.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
KEPPRA XR 500MG TABLET
|
Facility
|
IP
|
$4.72
|
|
|
Service Code
|
NDC 68001011306
|
| Hospital Charge Code |
25000819
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.92
|
| Rate for Payer: First Health Commercial |
$4.48
|
| Rate for Payer: Humana Commercial |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.15
|
| Rate for Payer: Ohio Health Group HMO |
$3.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
KEPPRA XR 750 MG TABLET
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 68001011406
|
| Hospital Charge Code |
25000820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.72
|
| Rate for Payer: Humana Commercial |
$4.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.37
|
| Rate for Payer: Ohio Health Group HMO |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
KEPPRA XR 750 MG TABLET
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 68001011406
|
| Hospital Charge Code |
25000820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Anthem Medicaid |
$1.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.88
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: First Health Commercial |
$4.72
|
| Rate for Payer: Humana Commercial |
$4.22
|
| Rate for Payer: Humana KY Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.37
|
| Rate for Payer: Ohio Health Group HMO |
$3.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.54
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
KETAMINE 1,000mg/10mL MDV
|
Facility
|
IP
|
$88.34
|
|
|
Service Code
|
NDC 55150044001
|
| Hospital Charge Code |
25004347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$84.81 |
| Rate for Payer: Aetna Commercial |
$68.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.91
|
| Rate for Payer: Cash Price |
$44.17
|
| Rate for Payer: Cigna Commercial |
$73.32
|
| Rate for Payer: First Health Commercial |
$83.92
|
| Rate for Payer: Humana Commercial |
$75.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.74
|
| Rate for Payer: Ohio Health Group HMO |
$66.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.39
|
| Rate for Payer: PHCS Commercial |
$84.81
|
| Rate for Payer: United Healthcare All Payer |
$77.74
|
|
|
KETAMINE 1,000mg/10mL MDV
|
Facility
|
OP
|
$88.34
|
|
|
Service Code
|
NDC 55150044001
|
| Hospital Charge Code |
25004347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$84.81 |
| Rate for Payer: Aetna Commercial |
$68.02
|
| Rate for Payer: Anthem Medicaid |
$30.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.91
|
| Rate for Payer: Cash Price |
$44.17
|
| Rate for Payer: Cigna Commercial |
$73.32
|
| Rate for Payer: First Health Commercial |
$83.92
|
| Rate for Payer: Humana Commercial |
$75.09
|
| Rate for Payer: Humana KY Medicaid |
$30.38
|
| Rate for Payer: Kentucky WC Medicaid |
$30.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.74
|
| Rate for Payer: Ohio Health Group HMO |
$66.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.39
|
| Rate for Payer: PHCS Commercial |
$84.81
|
| Rate for Payer: United Healthcare All Payer |
$77.74
|
|
|
KETAMINE 500 MG/ 10 ML VIAL
|
Facility
|
IP
|
$82.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$78.74 |
| Rate for Payer: Aetna Commercial |
$63.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.98
|
| Rate for Payer: Cash Price |
$41.01
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: First Health Commercial |
$77.92
|
| Rate for Payer: Humana Commercial |
$69.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.18
|
| Rate for Payer: Ohio Health Group HMO |
$61.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.43
|
| Rate for Payer: PHCS Commercial |
$78.74
|
| Rate for Payer: United Healthcare All Payer |
$72.18
|
|
|
KETAMINE 500 MG/ 10 ML VIAL
|
Facility
|
OP
|
$82.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$78.74 |
| Rate for Payer: Aetna Commercial |
$63.16
|
| Rate for Payer: Anthem Medicaid |
$28.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.98
|
| Rate for Payer: Cash Price |
$41.01
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: First Health Commercial |
$77.92
|
| Rate for Payer: Humana Commercial |
$69.72
|
| Rate for Payer: Humana KY Medicaid |
$28.21
|
| Rate for Payer: Kentucky WC Medicaid |
$28.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.18
|
| Rate for Payer: Ohio Health Group HMO |
$61.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.43
|
| Rate for Payer: PHCS Commercial |
$78.74
|
| Rate for Payer: United Healthcare All Payer |
$72.18
|
|
|
KETAMINE 500MG/5ML VIAL(5ML)
|
Facility
|
OP
|
$87.74
|
|
|
Service Code
|
NDC 409205115
|
| Hospital Charge Code |
25003148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$84.23 |
| Rate for Payer: Aetna Commercial |
$67.56
|
| Rate for Payer: Anthem Medicaid |
$30.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.44
|
| Rate for Payer: Cash Price |
$43.87
|
| Rate for Payer: Cigna Commercial |
$72.82
|
| Rate for Payer: First Health Commercial |
$83.35
|
| Rate for Payer: Humana Commercial |
$74.58
|
| Rate for Payer: Humana KY Medicaid |
$30.17
|
| Rate for Payer: Kentucky WC Medicaid |
$30.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.21
|
| Rate for Payer: Ohio Health Group HMO |
$65.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.20
|
| Rate for Payer: PHCS Commercial |
$84.23
|
| Rate for Payer: United Healthcare All Payer |
$77.21
|
|
|
KETAMINE 500MG/5ML VIAL(5ML)
|
Facility
|
IP
|
$87.74
|
|
|
Service Code
|
NDC 409205115
|
| Hospital Charge Code |
25003148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$84.23 |
| Rate for Payer: Aetna Commercial |
$67.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.44
|
| Rate for Payer: Cash Price |
$43.87
|
| Rate for Payer: Cigna Commercial |
$72.82
|
| Rate for Payer: First Health Commercial |
$83.35
|
| Rate for Payer: Humana Commercial |
$74.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.21
|
| Rate for Payer: Ohio Health Group HMO |
$65.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.20
|
| Rate for Payer: PHCS Commercial |
$84.23
|
| Rate for Payer: United Healthcare All Payer |
$77.21
|
|
|
KETAMINE 50MG/5ML SYRINGE
|
Facility
|
IP
|
$78.47
|
|
|
Service Code
|
NDC 143950910
|
| Hospital Charge Code |
25003149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$75.33 |
| Rate for Payer: Aetna Commercial |
$60.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.21
|
| Rate for Payer: Cash Price |
$39.24
|
| Rate for Payer: Cigna Commercial |
$65.13
|
| Rate for Payer: First Health Commercial |
$74.55
|
| Rate for Payer: Humana Commercial |
$66.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.05
|
| Rate for Payer: Ohio Health Group HMO |
$58.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.33
|
| Rate for Payer: PHCS Commercial |
$75.33
|
| Rate for Payer: United Healthcare All Payer |
$69.05
|
|
|
KETAMINE 50MG/5ML SYRINGE
|
Facility
|
OP
|
$78.47
|
|
|
Service Code
|
NDC 143950910
|
| Hospital Charge Code |
25003149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$75.33 |
| Rate for Payer: Aetna Commercial |
$60.42
|
| Rate for Payer: Anthem Medicaid |
$26.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.21
|
| Rate for Payer: Cash Price |
$39.24
|
| Rate for Payer: Cigna Commercial |
$65.13
|
| Rate for Payer: First Health Commercial |
$74.55
|
| Rate for Payer: Humana Commercial |
$66.70
|
| Rate for Payer: Humana KY Medicaid |
$26.99
|
| Rate for Payer: Kentucky WC Medicaid |
$27.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.05
|
| Rate for Payer: Ohio Health Group HMO |
$58.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.33
|
| Rate for Payer: PHCS Commercial |
$75.33
|
| Rate for Payer: United Healthcare All Payer |
$69.05
|
|
|
KETOCONAZOLE 2% Cream 15g
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna Commercial |
$4.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.68
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.98
|
| Rate for Payer: First Health Commercial |
$5.70
|
| Rate for Payer: Humana Commercial |
$5.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.28
|
| Rate for Payer: Ohio Health Group HMO |
$4.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.86
|
| Rate for Payer: PHCS Commercial |
$5.76
|
| Rate for Payer: United Healthcare All Payer |
$5.28
|
|
|
KETOCONAZOLE 2% Cream 15g
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna Commercial |
$4.62
|
| Rate for Payer: Anthem Medicaid |
$2.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.68
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.98
|
| Rate for Payer: First Health Commercial |
$5.70
|
| Rate for Payer: Humana Commercial |
$5.10
|
| Rate for Payer: Humana KY Medicaid |
$2.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.28
|
| Rate for Payer: Ohio Health Group HMO |
$4.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.86
|
| Rate for Payer: PHCS Commercial |
$5.76
|
| Rate for Payer: United Healthcare All Payer |
$5.28
|
|
