|
NALOXONE 0.01mg(2MG/2ML)
|
Facility
|
IP
|
$94.50
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
63600044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.35 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$72.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.71
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna Commercial |
$78.44
|
| Rate for Payer: First Health Commercial |
$89.78
|
| Rate for Payer: Humana Commercial |
$80.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.16
|
| Rate for Payer: Ohio Health Group HMO |
$70.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.20
|
| Rate for Payer: PHCS Commercial |
$90.72
|
| Rate for Payer: United Healthcare All Payer |
$83.16
|
|
|
NALOXONE 0.01mg(2MG/2ML)
|
Professional
|
Both
|
$94.50
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
63600044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Ambetter Exchange |
$0.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Multiplan PHCS |
$56.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$0.09
|
| Rate for Payer: UHCCP Medicaid |
$33.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.07
|
|
|
NALOXONE 0.01mg(2MG/2ML)
|
Facility
|
OP
|
$94.50
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
63600044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.35 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$72.77
|
| Rate for Payer: Anthem Medicaid |
$32.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.71
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna Commercial |
$78.44
|
| Rate for Payer: First Health Commercial |
$89.78
|
| Rate for Payer: Humana Commercial |
$80.33
|
| Rate for Payer: Humana KY Medicaid |
$32.50
|
| Rate for Payer: Kentucky WC Medicaid |
$32.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.16
|
| Rate for Payer: Ohio Health Group HMO |
$70.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.20
|
| Rate for Payer: PHCS Commercial |
$90.72
|
| Rate for Payer: United Healthcare All Payer |
$83.16
|
|
|
NALOXONE 0.01mg(2MG/2ML)
|
Facility
|
IP
|
$94.50
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
636T0044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.35 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$72.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.71
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna Commercial |
$78.44
|
| Rate for Payer: First Health Commercial |
$89.78
|
| Rate for Payer: Humana Commercial |
$80.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.16
|
| Rate for Payer: Ohio Health Group HMO |
$70.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.20
|
| Rate for Payer: PHCS Commercial |
$90.72
|
| Rate for Payer: United Healthcare All Payer |
$83.16
|
|
|
NALOXONE 0.01mg(2MG/2ML)
|
Facility
|
OP
|
$94.50
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
636T0044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.35 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna Commercial |
$72.77
|
| Rate for Payer: Anthem Medicaid |
$32.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.71
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna Commercial |
$78.44
|
| Rate for Payer: First Health Commercial |
$89.78
|
| Rate for Payer: Humana Commercial |
$80.33
|
| Rate for Payer: Humana KY Medicaid |
$32.50
|
| Rate for Payer: Kentucky WC Medicaid |
$32.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.16
|
| Rate for Payer: Ohio Health Group HMO |
$70.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.20
|
| Rate for Payer: PHCS Commercial |
$90.72
|
| Rate for Payer: United Healthcare All Payer |
$83.16
|
|
|
NALOXONE(0.01mg SDV) .4MG/2ML
|
Facility
|
OP
|
$86.27
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
25002257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.88 |
| Max. Negotiated Rate |
$82.82 |
| Rate for Payer: Aetna Commercial |
$66.43
|
| Rate for Payer: Anthem Medicaid |
$29.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.29
|
| Rate for Payer: Cash Price |
$43.13
|
| Rate for Payer: Cigna Commercial |
$71.60
|
| Rate for Payer: First Health Commercial |
$81.96
|
| Rate for Payer: Humana Commercial |
$73.33
|
| Rate for Payer: Humana KY Medicaid |
$29.67
|
| Rate for Payer: Kentucky WC Medicaid |
$29.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.92
|
| Rate for Payer: Ohio Health Group HMO |
$64.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.53
|
| Rate for Payer: PHCS Commercial |
$82.82
|
| Rate for Payer: United Healthcare All Payer |
$75.92
|
|
|
NALOXONE(0.01mg SDV) .4MG/2ML
|
Facility
|
IP
|
$86.27
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
25002257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.88 |
| Max. Negotiated Rate |
$82.82 |
| Rate for Payer: Aetna Commercial |
$66.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.29
|
| Rate for Payer: Cash Price |
$43.13
|
| Rate for Payer: Cigna Commercial |
$71.60
|
| Rate for Payer: First Health Commercial |
$81.96
|
| Rate for Payer: Humana Commercial |
$73.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.92
|
| Rate for Payer: Ohio Health Group HMO |
$64.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.53
|
| Rate for Payer: PHCS Commercial |
$82.82
|
| Rate for Payer: United Healthcare All Payer |
$75.92
|
|
|
NALTREXONE 1 MG
|
Facility
|
OP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
63600111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem Medicaid |
$8.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Humana KY Medicaid |
$8.34
|
| Rate for Payer: Humana Medicare Advantage |
$4.24
|
| Rate for Payer: Kentucky WC Medicaid |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
NALTREXONE 1 MG
|
Facility
|
OP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
636T0111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem Medicaid |
$8.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Humana KY Medicaid |
$8.34
|
| Rate for Payer: Humana Medicare Advantage |
$4.24
|
| Rate for Payer: Kentucky WC Medicaid |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
NALTREXONE 1 MG
|
Facility
|
IP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
636T0111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
NALTREXONE 1 MG
|
Professional
|
Both
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
63600111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$14.54 |
| Rate for Payer: Aetna Commercial |
$4.83
|
| Rate for Payer: Ambetter Exchange |
$4.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.09
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Healthspan PPO |
$2.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.24
|
| Rate for Payer: Multiplan PHCS |
$14.54
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.51
|
| Rate for Payer: UHCCP Medicaid |
$8.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.24
|
|
|
NALTREXONE 1 MG
|
Facility
|
IP
|
$24.24
|
|
|
Service Code
|
HCPCS J2315
|
| Hospital Charge Code |
63600111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$23.27 |
| Rate for Payer: Aetna Commercial |
$18.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.91
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cigna Commercial |
$20.12
|
| Rate for Payer: First Health Commercial |
$23.03
|
| Rate for Payer: Humana Commercial |
$20.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.33
|
| Rate for Payer: Ohio Health Group HMO |
$18.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$23.27
|
| Rate for Payer: United Healthcare All Payer |
$21.33
|
|
|
NALTREXONE 50MG TABLET
|
Facility
|
IP
|
$9.94
|
|
|
Service Code
|
NDC 406117003
|
| Hospital Charge Code |
25001041
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna Commercial |
$7.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Cash Price |
$4.97
|
| Rate for Payer: Cigna Commercial |
$8.25
|
| Rate for Payer: First Health Commercial |
$9.44
|
| Rate for Payer: Humana Commercial |
$8.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.75
|
| Rate for Payer: Ohio Health Group HMO |
$7.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.86
|
| Rate for Payer: PHCS Commercial |
$9.54
|
| Rate for Payer: United Healthcare All Payer |
$8.75
|
|
|
NALTREXONE 50MG TABLET
|
Facility
|
OP
|
$9.94
|
|
|
Service Code
|
NDC 406117003
|
| Hospital Charge Code |
25001041
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna Commercial |
$7.65
|
| Rate for Payer: Anthem Medicaid |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.75
|
| Rate for Payer: Cash Price |
$4.97
|
| Rate for Payer: Cigna Commercial |
$8.25
|
| Rate for Payer: First Health Commercial |
$9.44
|
| Rate for Payer: Humana Commercial |
$8.45
|
| Rate for Payer: Humana KY Medicaid |
$3.42
|
| Rate for Payer: Kentucky WC Medicaid |
$3.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.75
|
| Rate for Payer: Ohio Health Group HMO |
$7.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.86
|
| Rate for Payer: PHCS Commercial |
$9.54
|
| Rate for Payer: United Healthcare All Payer |
$8.75
|
|
|
NAMENDA (MEMANTINE) 10MG TAB
|
Facility
|
IP
|
$4.87
|
|
|
Service Code
|
NDC 60687018457
|
| Hospital Charge Code |
25001042
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
NAMENDA (MEMANTINE) 10MG TAB
|
Facility
|
OP
|
$4.87
|
|
|
Service Code
|
NDC 60687018457
|
| Hospital Charge Code |
25001042
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.75
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.80
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.04
|
| Rate for Payer: First Health Commercial |
$4.63
|
| Rate for Payer: Humana Commercial |
$4.14
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
NAMENDA (MEMANTINE) 5 MG TAB
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 60687017357
|
| Hospital Charge Code |
25001043
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| 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 |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.23
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
NAMENDA (MEMANTINE) 5 MG TAB
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 60687017357
|
| Hospital Charge Code |
25001043
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.49 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| 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 |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.23
|
| Rate for Payer: PHCS Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Payer |
$4.12
|
|
|
NANOCROS .014 OTWPTA 2*120*150
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
NANOCROS .014 OTWPTA 2*120*150
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
NANOCROS .014 OTWPTA 2*150*150
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
NANOCROS .014 OTWPTA 2*150*150
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
NANOCROS .014 OTWPTA 2*210*150
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
NANOCROS .014 OTWPTA 2*210*150
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
NANOCROS.014 OTWPTA 2.5*150*15
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
