|
NORCO 5/325MG EQ TABLET
|
Facility
|
OP
|
$60.10
|
|
|
Service Code
|
NDC 27808003501
|
| Hospital Charge Code |
25001095
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$57.70 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem Medicaid |
$20.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.88
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cigna Commercial |
$49.88
|
| Rate for Payer: First Health Commercial |
$57.09
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Humana KY Medicaid |
$20.67
|
| Rate for Payer: Kentucky WC Medicaid |
$20.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.89
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.47
|
| Rate for Payer: PHCS Commercial |
$57.70
|
| Rate for Payer: United Healthcare All Payer |
$52.89
|
|
|
NORCO 7.5/325MG EQ TABLET
|
Facility
|
IP
|
$60.21
|
|
|
Service Code
|
NDC 406012401
|
| Hospital Charge Code |
25001096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$57.80 |
| Rate for Payer: Aetna Commercial |
$46.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.96
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: Cigna Commercial |
$49.97
|
| Rate for Payer: First Health Commercial |
$57.20
|
| Rate for Payer: Humana Commercial |
$51.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.98
|
| Rate for Payer: Ohio Health Group HMO |
$45.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.54
|
| Rate for Payer: PHCS Commercial |
$57.80
|
| Rate for Payer: United Healthcare All Payer |
$52.98
|
|
|
NORCO 7.5/325MG EQ TABLET
|
Facility
|
OP
|
$60.21
|
|
|
Service Code
|
NDC 406012401
|
| Hospital Charge Code |
25001096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$57.80 |
| Rate for Payer: Aetna Commercial |
$46.36
|
| Rate for Payer: Anthem Medicaid |
$20.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.96
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: Cigna Commercial |
$49.97
|
| Rate for Payer: First Health Commercial |
$57.20
|
| Rate for Payer: Humana Commercial |
$51.18
|
| Rate for Payer: Humana KY Medicaid |
$20.71
|
| Rate for Payer: Kentucky WC Medicaid |
$20.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.98
|
| Rate for Payer: Ohio Health Group HMO |
$45.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.54
|
| Rate for Payer: PHCS Commercial |
$57.80
|
| Rate for Payer: United Healthcare All Payer |
$52.98
|
|
|
NORCURON (VERCURONIU 10MG/10ML
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 55150023501
|
| Hospital Charge Code |
25003298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.36
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$92.96
|
| Rate for Payer: First Health Commercial |
$106.40
|
| Rate for Payer: Humana Commercial |
$95.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.56
|
| Rate for Payer: Ohio Health Group HMO |
$84.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.28
|
| Rate for Payer: PHCS Commercial |
$107.52
|
| Rate for Payer: United Healthcare All Payer |
$98.56
|
|
|
NORCURON (VERCURONIU 10MG/10ML
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 55150023501
|
| Hospital Charge Code |
25003298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: Anthem Medicaid |
$38.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.36
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$92.96
|
| Rate for Payer: First Health Commercial |
$106.40
|
| Rate for Payer: Humana Commercial |
$95.20
|
| Rate for Payer: Humana KY Medicaid |
$38.52
|
| Rate for Payer: Kentucky WC Medicaid |
$38.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.56
|
| Rate for Payer: Ohio Health Group HMO |
$84.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.28
|
| Rate for Payer: PHCS Commercial |
$107.52
|
| Rate for Payer: United Healthcare All Payer |
$98.56
|
|
|
NOREPINEPHRINE 64MCG/ML 250ML
|
Facility
|
IP
|
$203.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003299
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$195.12 |
| Rate for Payer: Aetna Commercial |
$156.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.53
|
| Rate for Payer: Cash Price |
$101.62
|
| Rate for Payer: Cigna Commercial |
$168.70
|
| Rate for Payer: First Health Commercial |
$193.09
|
| Rate for Payer: Humana Commercial |
$172.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.86
|
| Rate for Payer: Ohio Health Group HMO |
$152.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.24
|
| Rate for Payer: PHCS Commercial |
$195.12
|
| Rate for Payer: United Healthcare All Payer |
$178.86
|
|
|
NOREPINEPHRINE 64MCG/ML 250ML
|
Facility
|
OP
|
$203.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003299
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$195.12 |
| Rate for Payer: Aetna Commercial |
$156.50
|
| Rate for Payer: Anthem Medicaid |
$69.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.53
|
| Rate for Payer: Cash Price |
$101.62
|
| Rate for Payer: Cigna Commercial |
$168.70
|
| Rate for Payer: First Health Commercial |
$193.09
|
| Rate for Payer: Humana Commercial |
$172.76
|
| Rate for Payer: Humana KY Medicaid |
$69.90
|
| Rate for Payer: Kentucky WC Medicaid |
$70.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.86
|
| Rate for Payer: Ohio Health Group HMO |
$152.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.24
|
| Rate for Payer: PHCS Commercial |
$195.12
|
| Rate for Payer: United Healthcare All Payer |
$178.86
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Facility
|
IP
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
63600045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$117.70 |
| Rate for Payer: Aetna Commercial |
$94.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.63
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cigna Commercial |
$101.76
|
| Rate for Payer: First Health Commercial |
$116.47
|
| Rate for Payer: Humana Commercial |
$104.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.89
|
| Rate for Payer: Ohio Health Group HMO |
$91.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.59
|
| Rate for Payer: PHCS Commercial |
$117.70
|
| Rate for Payer: United Healthcare All Payer |
$107.89
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Facility
|
IP
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
25002276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$117.70 |
| Rate for Payer: Aetna Commercial |
$94.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.63
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cigna Commercial |
$101.76
|
| Rate for Payer: First Health Commercial |
$116.47
|
| Rate for Payer: Humana Commercial |
$104.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.89
|
| Rate for Payer: Ohio Health Group HMO |
$91.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.59
|
| Rate for Payer: PHCS Commercial |
$117.70
|
| Rate for Payer: United Healthcare All Payer |
$107.89
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Facility
|
IP
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
636T0045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$117.70 |
| Rate for Payer: Aetna Commercial |
$94.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.63
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cigna Commercial |
$101.76
|
| Rate for Payer: First Health Commercial |
$116.47
|
| Rate for Payer: Humana Commercial |
$104.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.89
|
| Rate for Payer: Ohio Health Group HMO |
$91.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.59
|
| Rate for Payer: PHCS Commercial |
$117.70
|
| Rate for Payer: United Healthcare All Payer |
$107.89
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Facility
|
OP
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
63600045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$117.70 |
| Rate for Payer: Aetna Commercial |
$94.40
|
| Rate for Payer: Anthem Medicaid |
$42.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.63
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cigna Commercial |
$101.76
|
| Rate for Payer: First Health Commercial |
$116.47
|
| Rate for Payer: Humana Commercial |
$104.21
|
| Rate for Payer: Humana KY Medicaid |
$42.16
|
| Rate for Payer: Kentucky WC Medicaid |
$42.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.89
|
| Rate for Payer: Ohio Health Group HMO |
$91.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.59
|
| Rate for Payer: PHCS Commercial |
$117.70
|
| Rate for Payer: United Healthcare All Payer |
$107.89
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Facility
|
OP
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
25002276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$117.70 |
| Rate for Payer: Aetna Commercial |
$94.40
|
| Rate for Payer: Anthem Medicaid |
$42.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.63
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cigna Commercial |
$101.76
|
| Rate for Payer: First Health Commercial |
$116.47
|
| Rate for Payer: Humana Commercial |
$104.21
|
| Rate for Payer: Humana KY Medicaid |
$42.16
|
| Rate for Payer: Kentucky WC Medicaid |
$42.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.89
|
| Rate for Payer: Ohio Health Group HMO |
$91.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.59
|
| Rate for Payer: PHCS Commercial |
$117.70
|
| Rate for Payer: United Healthcare All Payer |
$107.89
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Facility
|
OP
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
636T0045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$117.70 |
| Rate for Payer: Aetna Commercial |
$94.40
|
| Rate for Payer: Anthem Medicaid |
$42.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.63
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cigna Commercial |
$101.76
|
| Rate for Payer: First Health Commercial |
$116.47
|
| Rate for Payer: Humana Commercial |
$104.21
|
| Rate for Payer: Humana KY Medicaid |
$42.16
|
| Rate for Payer: Kentucky WC Medicaid |
$42.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.89
|
| Rate for Payer: Ohio Health Group HMO |
$91.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.59
|
| Rate for Payer: PHCS Commercial |
$117.70
|
| Rate for Payer: United Healthcare All Payer |
$107.89
|
|
|
NORFLEX 60MG/2ML INJECTION
|
Professional
|
Both
|
$122.60
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
63600045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$73.56 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Ambetter Exchange |
$9.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.34
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Cash Price |
$61.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$9.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.45
|
| Rate for Payer: Multiplan PHCS |
$73.56
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$12.29
|
| Rate for Payer: UHCCP Medicaid |
$42.91
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.45
|
|
|
NORFLEX(ORPHENADRIN 100MG/1TAB
|
Facility
|
IP
|
$4.90
|
|
|
Service Code
|
NDC 43386048024
|
| Hospital Charge Code |
25001097
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cigna Commercial |
$4.07
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.31
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Payer |
$4.31
|
|
|
NORFLEX(ORPHENADRIN 100MG/1TAB
|
Facility
|
OP
|
$4.90
|
|
|
Service Code
|
NDC 43386048024
|
| Hospital Charge Code |
25001097
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cigna Commercial |
$4.07
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.31
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Payer |
$4.31
|
|
|
NORMODYNE 100MG/20ML VIAL
|
Facility
|
IP
|
$79.96
|
|
|
Service Code
|
NDC 409012501
|
| Hospital Charge Code |
25003301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.76 |
| Rate for Payer: Aetna Commercial |
$61.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.37
|
| Rate for Payer: Cash Price |
$39.98
|
| Rate for Payer: Cigna Commercial |
$66.37
|
| Rate for Payer: First Health Commercial |
$75.96
|
| Rate for Payer: Humana Commercial |
$67.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.17
|
| Rate for Payer: PHCS Commercial |
$76.76
|
| Rate for Payer: United Healthcare All Payer |
$70.36
|
|
|
NORMODYNE 100MG/20ML VIAL
|
Facility
|
OP
|
$79.96
|
|
|
Service Code
|
NDC 409012501
|
| Hospital Charge Code |
25003301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$76.76 |
| Rate for Payer: Aetna Commercial |
$61.57
|
| Rate for Payer: Anthem Medicaid |
$27.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.37
|
| Rate for Payer: Cash Price |
$39.98
|
| Rate for Payer: Cigna Commercial |
$66.37
|
| Rate for Payer: First Health Commercial |
$75.96
|
| Rate for Payer: Humana Commercial |
$67.97
|
| Rate for Payer: Humana KY Medicaid |
$27.50
|
| Rate for Payer: Kentucky WC Medicaid |
$27.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.17
|
| Rate for Payer: PHCS Commercial |
$76.76
|
| Rate for Payer: United Healthcare All Payer |
$70.36
|
|
|
NORMODYNE (LABETALO 200MG/1TAB
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 60687045001
|
| Hospital Charge Code |
25001098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
NORMODYNE (LABETALO 200MG/1TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 60687045001
|
| Hospital Charge Code |
25001098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
NORMODYNE (LABETALOL) 100MGTAB
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 60687043901
|
| Hospital Charge Code |
25001099
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.21
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
NORMODYNE (LABETALOL) 100MGTAB
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
NDC 60687043901
|
| Hospital Charge Code |
25001099
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.86
|
| Rate for Payer: First Health Commercial |
$4.42
|
| Rate for Payer: Humana Commercial |
$3.95
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.09
|
| Rate for Payer: Ohio Health Group HMO |
$3.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.21
|
| Rate for Payer: PHCS Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Payer |
$4.09
|
|
|
NORMOSOL-R(PH 7.4)IVSOL 1000ML
|
Facility
|
IP
|
$112.25
|
|
|
Service Code
|
NDC 990767009
|
| Hospital Charge Code |
25003302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$107.76 |
| Rate for Payer: Aetna Commercial |
$86.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.56
|
| Rate for Payer: Cash Price |
$56.12
|
| Rate for Payer: Cigna Commercial |
$93.17
|
| Rate for Payer: First Health Commercial |
$106.64
|
| Rate for Payer: Humana Commercial |
$95.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.78
|
| Rate for Payer: Ohio Health Group HMO |
$84.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.45
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
NORMOSOL-R(PH 7.4)IVSOL 1000ML
|
Facility
|
OP
|
$112.25
|
|
|
Service Code
|
NDC 990767009
|
| Hospital Charge Code |
25003302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$107.76 |
| Rate for Payer: Aetna Commercial |
$86.43
|
| Rate for Payer: Anthem Medicaid |
$38.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.56
|
| Rate for Payer: Cash Price |
$56.12
|
| Rate for Payer: Cigna Commercial |
$93.17
|
| Rate for Payer: First Health Commercial |
$106.64
|
| Rate for Payer: Humana Commercial |
$95.41
|
| Rate for Payer: Humana KY Medicaid |
$38.60
|
| Rate for Payer: Kentucky WC Medicaid |
$39.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.78
|
| Rate for Payer: Ohio Health Group HMO |
$84.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$89.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.45
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
NORPACE (DISOPYRAMI 100MG/1CAP
|
Facility
|
IP
|
$9.99
|
|
|
Service Code
|
NDC 93312701
|
| Hospital Charge Code |
25001100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$9.59 |
| Rate for Payer: Aetna Commercial |
$7.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.79
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cigna Commercial |
$8.29
|
| Rate for Payer: First Health Commercial |
$9.49
|
| Rate for Payer: Humana Commercial |
$8.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.79
|
| Rate for Payer: Ohio Health Group HMO |
$7.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$9.59
|
| Rate for Payer: United Healthcare All Payer |
$8.79
|
|
