|
DELTOID LIGMNT RECON IMP SYS
|
Facility
|
OP
|
$9,935.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,291.65 |
| Max. Negotiated Rate |
$9,538.32 |
| Rate for Payer: Aetna Commercial |
$7,650.53
|
| Rate for Payer: Anthem Medicaid |
$3,416.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.88
|
| Rate for Payer: Cash Price |
$4,967.88
|
| Rate for Payer: Cigna Commercial |
$8,246.67
|
| Rate for Payer: First Health Commercial |
$9,438.96
|
| Rate for Payer: Humana Commercial |
$8,445.39
|
| Rate for Payer: Humana KY Medicaid |
$3,416.90
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,147.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,743.46
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,987.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,291.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,080.08
|
| Rate for Payer: PHCS Commercial |
$9,538.32
|
| Rate for Payer: United Healthcare All Payer |
$8,743.46
|
|
|
DELZICOL 400 MG CAPSULE
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 59762011701
|
| Hospital Charge Code |
25000526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
DELZICOL 400 MG CAPSULE
|
Facility
|
OP
|
$10.33
|
|
|
Service Code
|
NDC 59762011701
|
| Hospital Charge Code |
25000526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem Medicaid |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Humana KY Medicaid |
$3.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
DEMADEX (TORSEMIDE) 20MG/1TAB
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
25000527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
DEMADEX (TORSEMIDE) 20MG/1TAB
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
25000527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
DEMEROL [100 MG] 50MG/1ML INJ
|
Facility
|
OP
|
$77.32
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25002222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$74.23 |
| Rate for Payer: Aetna Commercial |
$59.54
|
| Rate for Payer: Anthem Medicaid |
$26.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.31
|
| Rate for Payer: Cash Price |
$38.66
|
| Rate for Payer: Cigna Commercial |
$64.18
|
| Rate for Payer: First Health Commercial |
$73.45
|
| Rate for Payer: Humana Commercial |
$65.72
|
| Rate for Payer: Humana KY Medicaid |
$26.59
|
| Rate for Payer: Kentucky WC Medicaid |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.04
|
| Rate for Payer: Ohio Health Group HMO |
$57.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.97
|
| Rate for Payer: PHCS Commercial |
$74.23
|
| Rate for Payer: United Healthcare All Payer |
$68.04
|
|
|
DEMEROL [100 MG] 50MG/1ML INJ
|
Facility
|
IP
|
$77.32
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25002222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$74.23 |
| Rate for Payer: Aetna Commercial |
$59.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.31
|
| Rate for Payer: Cash Price |
$38.66
|
| Rate for Payer: Cigna Commercial |
$64.18
|
| Rate for Payer: First Health Commercial |
$73.45
|
| Rate for Payer: Humana Commercial |
$65.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.04
|
| Rate for Payer: Ohio Health Group HMO |
$57.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.97
|
| Rate for Payer: PHCS Commercial |
$74.23
|
| Rate for Payer: United Healthcare All Payer |
$68.04
|
|
|
DEMEROL [100 MG] 75MG/1ML INJ
|
Facility
|
OP
|
$81.40
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25002223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$78.14 |
| Rate for Payer: Aetna Commercial |
$62.68
|
| Rate for Payer: Anthem Medicaid |
$27.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.49
|
| Rate for Payer: Cash Price |
$40.70
|
| Rate for Payer: Cigna Commercial |
$67.56
|
| Rate for Payer: First Health Commercial |
$77.33
|
| Rate for Payer: Humana Commercial |
$69.19
|
| Rate for Payer: Humana KY Medicaid |
$27.99
|
| Rate for Payer: Kentucky WC Medicaid |
$28.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.63
|
| Rate for Payer: Ohio Health Group HMO |
$61.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.23
|
| Rate for Payer: PHCS Commercial |
$78.14
|
| Rate for Payer: United Healthcare All Payer |
$71.63
|
|
|
DEMEROL [100 MG] 75MG/1ML INJ
|
Facility
|
IP
|
$81.40
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25002223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$78.14 |
| Rate for Payer: Aetna Commercial |
$62.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.49
|
| Rate for Payer: Cash Price |
$40.70
|
| Rate for Payer: Cigna Commercial |
$67.56
|
| Rate for Payer: First Health Commercial |
$77.33
|
| Rate for Payer: Humana Commercial |
$69.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.63
|
| Rate for Payer: Ohio Health Group HMO |
$61.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.23
|
| Rate for Payer: PHCS Commercial |
$78.14
|
| Rate for Payer: United Healthcare All Payer |
$71.63
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$10,978.76
|
|
|
Service Code
|
MSDRG 158
|
| Min. Negotiated Rate |
$7,449.87 |
| Max. Negotiated Rate |
$10,978.76 |
| Rate for Payer: Anthem Medicaid |
$7,449.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,841.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,978.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,586.66
|
| Rate for Payer: Humana KY Medicaid |
$7,449.87
|
| Rate for Payer: Humana Medicare Advantage |
$7,841.97
|
| Rate for Payer: Kentucky WC Medicaid |
$7,524.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,410.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,598.87
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$19,968.84
|
|
|
Service Code
|
MSDRG 157
|
| Min. Negotiated Rate |
$13,550.29 |
| Max. Negotiated Rate |
$19,968.84 |
| Rate for Payer: Anthem Medicaid |
$13,550.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14,263.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,968.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$19,255.67
|
| Rate for Payer: Humana KY Medicaid |
$13,550.29
|
| Rate for Payer: Humana Medicare Advantage |
$14,263.46
|
| Rate for Payer: Kentucky WC Medicaid |
$13,685.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,116.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,821.29
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$7,898.63
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$5,359.79 |
| Max. Negotiated Rate |
$7,898.63 |
| Rate for Payer: Anthem Medicaid |
$5,359.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,641.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,898.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,616.54
|
| Rate for Payer: Humana KY Medicaid |
$5,359.79
|
| Rate for Payer: Humana Medicare Advantage |
$5,641.88
|
| Rate for Payer: Kentucky WC Medicaid |
$5,413.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,770.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,466.98
|
|
|
DEPACON(VALPROATE S 500MG/5ML)
|
Facility
|
OP
|
$124.29
|
|
|
Service Code
|
NDC 143978510
|
| Hospital Charge Code |
25002984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.16 |
| Max. Negotiated Rate |
$119.32 |
| Rate for Payer: Humana Commercial |
$105.65
|
| Rate for Payer: Humana KY Medicaid |
$42.74
|
| Rate for Payer: Kentucky WC Medicaid |
$43.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.38
|
| Rate for Payer: Ohio Health Group HMO |
$93.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.53
|
| Rate for Payer: PHCS Commercial |
$119.32
|
| Rate for Payer: United Healthcare All Payer |
$109.38
|
| Rate for Payer: Aetna Commercial |
$95.70
|
| Rate for Payer: Anthem Medicaid |
$42.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.95
|
| Rate for Payer: Cash Price |
$62.15
|
| Rate for Payer: Cigna Commercial |
$103.16
|
| Rate for Payer: First Health Commercial |
$118.08
|
|
|
DEPACON(VALPROATE S 500MG/5ML)
|
Facility
|
IP
|
$124.29
|
|
|
Service Code
|
NDC 143978510
|
| Hospital Charge Code |
25002984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.16 |
| Max. Negotiated Rate |
$119.32 |
| Rate for Payer: Aetna Commercial |
$95.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.95
|
| Rate for Payer: Cash Price |
$62.15
|
| Rate for Payer: Cigna Commercial |
$103.16
|
| Rate for Payer: First Health Commercial |
$118.08
|
| Rate for Payer: Humana Commercial |
$105.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.38
|
| Rate for Payer: Ohio Health Group HMO |
$93.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.53
|
| Rate for Payer: PHCS Commercial |
$119.32
|
| Rate for Payer: United Healthcare All Payer |
$109.38
|
|
|
DEPAKENE (VALPROATE) 250MG/5ML
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 121067516
|
| Hospital Charge Code |
25000529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
DEPAKENE (VALPROATE) 250MG/5ML
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 121067516
|
| Hospital Charge Code |
25000529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
DEPAKENE(VALPROIC A 250MG/1CAP
|
Facility
|
OP
|
$4.63
|
|
|
Service Code
|
NDC 63739008610
|
| Hospital Charge Code |
25000530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
DEPAKENE(VALPROIC A 250MG/1CAP
|
Facility
|
IP
|
$4.63
|
|
|
Service Code
|
NDC 63739008610
|
| Hospital Charge Code |
25000530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
DEPAKOTE 500 MG TAB
|
Facility
|
OP
|
$24.09
|
|
|
Service Code
|
NDC 74732713
|
| Hospital Charge Code |
25000532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$23.13 |
| Rate for Payer: Aetna Commercial |
$18.55
|
| Rate for Payer: Anthem Medicaid |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.79
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.99
|
| Rate for Payer: First Health Commercial |
$22.89
|
| Rate for Payer: Humana Commercial |
$20.48
|
| Rate for Payer: Humana KY Medicaid |
$8.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.20
|
| Rate for Payer: Ohio Health Group HMO |
$18.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.47
|
| Rate for Payer: PHCS Commercial |
$23.13
|
| Rate for Payer: United Healthcare All Payer |
$21.20
|
|
|
DEPAKOTE 500 MG TAB
|
Facility
|
IP
|
$24.09
|
|
|
Service Code
|
NDC 74732713
|
| Hospital Charge Code |
25000532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$23.13 |
| Rate for Payer: Humana Commercial |
$20.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.20
|
| Rate for Payer: Ohio Health Group HMO |
$18.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.47
|
| Rate for Payer: PHCS Commercial |
$23.13
|
| Rate for Payer: United Healthcare All Payer |
$21.20
|
| Rate for Payer: Aetna Commercial |
$18.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.79
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.99
|
| Rate for Payer: First Health Commercial |
$22.89
|
|
|
DEPAKOTE EC(DIVALPROET)125MG T
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
25000533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
DEPAKOTE EC(DIVALPROET)125MG T
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
25000533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
DEPAKOTE ER 500 MG TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 65862059501
|
| Hospital Charge Code |
25000534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| 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 |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| 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 |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
DEPAKOTE ER 500 MG TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 65862059501
|
| Hospital Charge Code |
25000534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| 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 |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| 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 |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
DEPAKOTE ER DIVALP SOD 250MG T
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 65862059401
|
| Hospital Charge Code |
25000535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
