|
KENALOG 10MG(from 50mg MDV)
|
Facility
|
IP
|
$13.19
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
25004568
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$12.66 |
| Rate for Payer: Aetna Commercial |
$10.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.29
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$10.95
|
| Rate for Payer: First Health Commercial |
$12.53
|
| Rate for Payer: Humana Commercial |
$11.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.61
|
| Rate for Payer: Ohio Health Group HMO |
$9.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.10
|
| Rate for Payer: PHCS Commercial |
$12.66
|
| Rate for Payer: United Healthcare All Payer |
$11.61
|
|
|
KENALOG LUBRIDER 40MG/120MLLOT
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
NDC 3029305
|
| Hospital Charge Code |
25000816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.03
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
KENALOG LUBRIDER 40MG/120MLLOT
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
NDC 3029305
|
| Hospital Charge Code |
25000816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem Medicaid |
$29.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Humana KY Medicaid |
$29.92
|
| Rate for Payer: Kentucky WC Medicaid |
$30.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.03
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
KENALOG(TRIAMCINOLONE)IN O 5GM
|
Facility
|
IP
|
$9.98
|
|
|
Service Code
|
NDC 64980032005
|
| Hospital Charge Code |
25000817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.99 |
| 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 |
$7.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$9.58
|
| Rate for Payer: United Healthcare All Payer |
$8.78
|
|
|
KENALOG(TRIAMCINOLONE)IN O 5GM
|
Facility
|
OP
|
$9.98
|
|
|
Service Code
|
NDC 64980032005
|
| Hospital Charge Code |
25000817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$7.68
|
| Rate for Payer: Anthem Medicaid |
$3.43
|
| 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: Humana KY Medicaid |
$3.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3.47
|
| 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: Molina Healthcare Medicaid |
$3.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.78
|
| Rate for Payer: Ohio Health Group HMO |
$7.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$9.58
|
| Rate for Payer: United Healthcare All Payer |
$8.78
|
|
|
KEPPRA 10MG(1500MG PREMIX)
|
Facility
|
IP
|
$58.64
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$56.29 |
| Rate for Payer: Aetna Commercial |
$45.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.74
|
| Rate for Payer: Cash Price |
$29.32
|
| Rate for Payer: Cigna Commercial |
$48.67
|
| Rate for Payer: First Health Commercial |
$55.71
|
| Rate for Payer: Humana Commercial |
$49.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$48.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$43.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$51.60
|
| Rate for Payer: Ohio Health Group HMO |
$43.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.46
|
| Rate for Payer: PHCS Commercial |
$56.29
|
| Rate for Payer: United Healthcare All Payer |
$51.60
|
|
|
KEPPRA 10MG(1500MG PREMIX)
|
Facility
|
OP
|
$58.64
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25004559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$56.29 |
| Rate for Payer: Aetna Commercial |
$45.15
|
| Rate for Payer: Anthem Medicaid |
$20.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.74
|
| Rate for Payer: Cash Price |
$29.32
|
| Rate for Payer: Cigna Commercial |
$48.67
|
| Rate for Payer: First Health Commercial |
$55.71
|
| Rate for Payer: Humana Commercial |
$49.84
|
| Rate for Payer: Humana KY Medicaid |
$20.17
|
| Rate for Payer: Kentucky WC Medicaid |
$20.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$48.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$43.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$51.60
|
| Rate for Payer: Ohio Health Group HMO |
$43.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.46
|
| Rate for Payer: PHCS Commercial |
$56.29
|
| Rate for Payer: United Healthcare All Payer |
$51.60
|
|
|
KEPPRA 10MG [500MG/5ML VIAL]
|
Facility
|
OP
|
$79.89
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25002208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.97 |
| 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 |
$63.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.12
|
| 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 |
$23.97 |
| 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 |
$63.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.12
|
| 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 |
$1.33 |
| 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 |
$1.33
|
| 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 |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| 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 |
$1.33 |
| 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 |
$1.33
|
| 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 |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
KEPPRA(LEVETIRACETM)500 MG TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
25000822
|
|
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
|
|
|
KEPPRA(LEVETIRACETM)500 MG TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
25000822
|
|
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
|
|
|
KEPPRA (PREMIX)1000MG/100ML IV
|
Facility
|
IP
|
$117.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
25002207
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.15 |
| 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 |
$87.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.85
|
| 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 |
$35.15 |
| 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 |
$87.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.85
|
| Rate for Payer: PHCS Commercial |
$112.49
|
| Rate for Payer: United Healthcare All Payer |
$103.12
|
|
|
KEPPRA SF 100MG/ML 5ML SOL
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
25000818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| 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 |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
KEPPRA SF 100MG/ML 5ML SOL
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
25000818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| 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 |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
KEPPRA XR 500MG TABLET
|
Facility
|
IP
|
$4.72
|
|
|
Service Code
|
NDC 68001011306
|
| Hospital Charge Code |
25000819
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| 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 |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
KEPPRA XR 500MG TABLET
|
Facility
|
OP
|
$4.72
|
|
|
Service Code
|
NDC 68001011306
|
| Hospital Charge Code |
25000819
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| 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 |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
KEPPRA XR 750 MG TABLET
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 68001011406
|
| Hospital Charge Code |
25000820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.43
|
| Rate for Payer: PHCS Commercial |
$4.77
|
| Rate for Payer: United Healthcare All Payer |
$4.37
|
|
|
KEPPRA XR 750 MG TABLET
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 68001011406
|
| Hospital Charge Code |
25000820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$3.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.43
|
| 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 |
$26.50 |
| 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 |
$66.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.95
|
| 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 |
$26.50 |
| 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 |
$66.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.95
|
| 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
|
890
|
| Min. Negotiated Rate |
$24.61 |
| 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 |
$65.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.59
|
| 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
|
890
|
| Min. Negotiated Rate |
$24.61 |
| 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 |
$65.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.59
|
| Rate for Payer: PHCS Commercial |
$78.74
|
| Rate for Payer: United Healthcare All Payer |
$72.18
|
|
