|
DEPAKOTE ER DIVALP SOD 250MG T
|
Facility
|
OP
|
$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 Medicaid |
$1.49
|
| 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: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| 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: Molina Healthcare Medicaid |
$1.52
|
| 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
|
|
|
DEPAKOT ER(DIVALPR SOD)250MG T
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
25000531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| 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 |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
DEPAKOT ER(DIVALPR SOD)250MG T
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
25000531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| 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 |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
DEPAKOTE SPRNKLE 125MG CAPSULE
|
Facility
|
IP
|
$4.76
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
25000536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: First Health Commercial |
$4.52
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.19
|
| Rate for Payer: Ohio Health Group HMO |
$3.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
|
|
DEPAKOTE SPRNKLE 125MG CAPSULE
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
25000536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.19
|
| Rate for Payer: Ohio Health Group HMO |
$3.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: First Health Commercial |
$4.52
|
|
|
DEPLIN 7.5MG TABLET
|
Facility
|
IP
|
$23.28
|
|
|
Service Code
|
NDC 525113990
|
| Hospital Charge Code |
25000537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$22.35 |
| Rate for Payer: Aetna Commercial |
$17.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.16
|
| Rate for Payer: Cash Price |
$11.64
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: First Health Commercial |
$22.12
|
| Rate for Payer: Humana Commercial |
$19.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.49
|
| Rate for Payer: Ohio Health Group HMO |
$17.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.22
|
| Rate for Payer: PHCS Commercial |
$22.35
|
| Rate for Payer: United Healthcare All Payer |
$20.49
|
|
|
DEPLIN 7.5MG TABLET
|
Facility
|
OP
|
$23.28
|
|
|
Service Code
|
NDC 525113990
|
| Hospital Charge Code |
25000537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$22.35 |
| Rate for Payer: Aetna Commercial |
$17.93
|
| Rate for Payer: Anthem Medicaid |
$8.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.16
|
| Rate for Payer: Cash Price |
$11.64
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: First Health Commercial |
$22.12
|
| Rate for Payer: Humana Commercial |
$19.79
|
| Rate for Payer: Humana KY Medicaid |
$8.01
|
| Rate for Payer: Kentucky WC Medicaid |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.49
|
| Rate for Payer: Ohio Health Group HMO |
$17.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.22
|
| Rate for Payer: PHCS Commercial |
$22.35
|
| Rate for Payer: United Healthcare All Payer |
$20.49
|
|
|
DEPOMEDROL 1MG (40MG SDV)
|
Facility
|
IP
|
$116.64
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
25002006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$111.97 |
| Rate for Payer: Aetna Commercial |
$89.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.98
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cigna Commercial |
$96.81
|
| Rate for Payer: First Health Commercial |
$110.81
|
| Rate for Payer: Humana Commercial |
$99.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.64
|
| Rate for Payer: Ohio Health Group HMO |
$87.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.16
|
| Rate for Payer: PHCS Commercial |
$111.97
|
| Rate for Payer: United Healthcare All Payer |
$102.64
|
|
|
DEPOMEDROL 1MG (40MG SDV)
|
Facility
|
OP
|
$116.64
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
25002006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$111.97 |
| Rate for Payer: Aetna Commercial |
$89.81
|
| Rate for Payer: Anthem Medicaid |
$40.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.98
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cigna Commercial |
$96.81
|
| Rate for Payer: First Health Commercial |
$110.81
|
| Rate for Payer: Humana Commercial |
$99.14
|
| Rate for Payer: Humana KY Medicaid |
$40.11
|
| Rate for Payer: Kentucky WC Medicaid |
$40.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.64
|
| Rate for Payer: Ohio Health Group HMO |
$87.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.16
|
| Rate for Payer: PHCS Commercial |
$111.97
|
| Rate for Payer: United Healthcare All Payer |
$102.64
|
|
|
DEPOMEDROL 1MG (80MG SDV)
|
Facility
|
IP
|
$123.32
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
25002007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.03 |
| Max. Negotiated Rate |
$118.39 |
| Rate for Payer: Aetna Commercial |
$94.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.19
|
| Rate for Payer: Cash Price |
$61.66
|
| Rate for Payer: Cigna Commercial |
$102.36
|
| Rate for Payer: First Health Commercial |
$117.15
|
| Rate for Payer: Humana Commercial |
$104.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.52
|
| Rate for Payer: Ohio Health Group HMO |
$92.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.23
|
| Rate for Payer: PHCS Commercial |
$118.39
|
| Rate for Payer: United Healthcare All Payer |
$108.52
|
|
|
DEPOMEDROL 1MG (80MG SDV)
|
Facility
|
OP
|
$123.32
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
25002007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.03 |
| Max. Negotiated Rate |
$118.39 |
| Rate for Payer: Aetna Commercial |
$94.96
|
| Rate for Payer: Anthem Medicaid |
$42.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.19
|
| Rate for Payer: Cash Price |
$61.66
|
| Rate for Payer: Cigna Commercial |
$102.36
|
| Rate for Payer: First Health Commercial |
$117.15
|
| Rate for Payer: Humana Commercial |
$104.82
|
| Rate for Payer: Humana KY Medicaid |
$42.41
|
| Rate for Payer: Kentucky WC Medicaid |
$42.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.52
|
| Rate for Payer: Ohio Health Group HMO |
$92.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.23
|
| Rate for Payer: PHCS Commercial |
$118.39
|
| Rate for Payer: United Healthcare All Payer |
$108.52
|
|
|
DEPO-MEDROL 80MG/1ML VIAL
|
Facility
|
OP
|
$120.43
|
|
|
Service Code
|
HCPCS J1040
|
| Hospital Charge Code |
63600026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$115.61 |
| Rate for Payer: Aetna Commercial |
$92.73
|
| Rate for Payer: Anthem Medicaid |
$41.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.94
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Cigna Commercial |
$99.96
|
| Rate for Payer: First Health Commercial |
$114.41
|
| Rate for Payer: Humana Commercial |
$102.37
|
| Rate for Payer: Humana KY Medicaid |
$41.42
|
| Rate for Payer: Kentucky WC Medicaid |
$41.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.98
|
| Rate for Payer: Ohio Health Group HMO |
$90.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.33
|
| Rate for Payer: PHCS Commercial |
$115.61
|
| Rate for Payer: United Healthcare All Payer |
$105.98
|
|
|
DEPO-MEDROL 80MG/1ML VIAL
|
Facility
|
IP
|
$120.43
|
|
|
Service Code
|
HCPCS J1040
|
| Hospital Charge Code |
63600026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$115.61 |
| Rate for Payer: Aetna Commercial |
$92.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.94
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Cigna Commercial |
$99.96
|
| Rate for Payer: First Health Commercial |
$114.41
|
| Rate for Payer: Humana Commercial |
$102.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.98
|
| Rate for Payer: Ohio Health Group HMO |
$90.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.33
|
| Rate for Payer: PHCS Commercial |
$115.61
|
| Rate for Payer: United Healthcare All Payer |
$105.98
|
|
|
DEPO-MEDROL 80MG/1ML VIAL
|
Professional
|
Both
|
$120.43
|
|
|
Service Code
|
HCPCS J1040
|
| Hospital Charge Code |
63600026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.61 |
| Max. Negotiated Rate |
$120.43 |
| Rate for Payer: Aetna Commercial |
$14.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.43
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.23
|
| Rate for Payer: Multiplan PHCS |
$72.26
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.30
|
| Rate for Payer: UHCCP Medicaid |
$42.15
|
|
|
DEPO-MEDROL 80MG/1ML VIAL
|
Facility
|
OP
|
$120.43
|
|
|
Service Code
|
HCPCS J1040
|
| Hospital Charge Code |
636T0026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$115.61 |
| Rate for Payer: Aetna Commercial |
$92.73
|
| Rate for Payer: Anthem Medicaid |
$41.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.94
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Cigna Commercial |
$99.96
|
| Rate for Payer: First Health Commercial |
$114.41
|
| Rate for Payer: Humana Commercial |
$102.37
|
| Rate for Payer: Humana KY Medicaid |
$41.42
|
| Rate for Payer: Kentucky WC Medicaid |
$41.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.98
|
| Rate for Payer: Ohio Health Group HMO |
$90.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.33
|
| Rate for Payer: PHCS Commercial |
$115.61
|
| Rate for Payer: United Healthcare All Payer |
$105.98
|
|
|
DEPO-MEDROL 80MG/1ML VIAL
|
Facility
|
IP
|
$120.43
|
|
|
Service Code
|
HCPCS J1040
|
| Hospital Charge Code |
636T0026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$115.61 |
| Rate for Payer: Aetna Commercial |
$92.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.94
|
| Rate for Payer: Cash Price |
$60.22
|
| Rate for Payer: Cigna Commercial |
$99.96
|
| Rate for Payer: First Health Commercial |
$114.41
|
| Rate for Payer: Humana Commercial |
$102.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.98
|
| Rate for Payer: Ohio Health Group HMO |
$90.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.33
|
| Rate for Payer: PHCS Commercial |
$115.61
|
| Rate for Payer: United Healthcare All Payer |
$105.98
|
|
|
DEPO MEDROL(METHYLPRE 40MG/1ML
|
Facility
|
IP
|
$112.62
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
636T0025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.64 |
| Max. Negotiated Rate |
$108.12 |
| Rate for Payer: Aetna Commercial |
$86.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.84
|
| Rate for Payer: Cash Price |
$56.31
|
| Rate for Payer: Cigna Commercial |
$93.47
|
| Rate for Payer: First Health Commercial |
$106.99
|
| Rate for Payer: Humana Commercial |
$95.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.11
|
| Rate for Payer: Ohio Health Group HMO |
$84.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.91
|
| Rate for Payer: PHCS Commercial |
$108.12
|
| Rate for Payer: United Healthcare All Payer |
$99.11
|
|
|
DEPO MEDROL(METHYLPRE 40MG/1ML
|
Facility
|
OP
|
$112.62
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
636T0025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.64 |
| Max. Negotiated Rate |
$108.12 |
| Rate for Payer: Aetna Commercial |
$86.72
|
| Rate for Payer: Anthem Medicaid |
$38.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.84
|
| Rate for Payer: Cash Price |
$56.31
|
| Rate for Payer: Cigna Commercial |
$93.47
|
| Rate for Payer: First Health Commercial |
$106.99
|
| Rate for Payer: Humana Commercial |
$95.73
|
| Rate for Payer: Humana KY Medicaid |
$38.73
|
| Rate for Payer: Kentucky WC Medicaid |
$39.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.11
|
| Rate for Payer: Ohio Health Group HMO |
$84.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.91
|
| Rate for Payer: PHCS Commercial |
$108.12
|
| Rate for Payer: United Healthcare All Payer |
$99.11
|
|
|
DEPO MEDROL(METHYLPRE 40MG/1ML
|
Facility
|
OP
|
$112.62
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
63600025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.64 |
| Max. Negotiated Rate |
$108.12 |
| Rate for Payer: Aetna Commercial |
$86.72
|
| Rate for Payer: Anthem Medicaid |
$38.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.84
|
| Rate for Payer: Cash Price |
$56.31
|
| Rate for Payer: Cigna Commercial |
$93.47
|
| Rate for Payer: First Health Commercial |
$106.99
|
| Rate for Payer: Humana Commercial |
$95.73
|
| Rate for Payer: Humana KY Medicaid |
$38.73
|
| Rate for Payer: Kentucky WC Medicaid |
$39.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.11
|
| Rate for Payer: Ohio Health Group HMO |
$84.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.91
|
| Rate for Payer: PHCS Commercial |
$108.12
|
| Rate for Payer: United Healthcare All Payer |
$99.11
|
|
|
DEPO MEDROL(METHYLPRE 40MG/1ML
|
Professional
|
Both
|
$112.62
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
63600025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$112.62 |
| Rate for Payer: Aetna Commercial |
$7.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$112.62
|
| Rate for Payer: Cash Price |
$56.31
|
| Rate for Payer: Cash Price |
$56.31
|
| Rate for Payer: Healthspan PPO |
$6.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.14
|
| Rate for Payer: Multiplan PHCS |
$67.57
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.83
|
| Rate for Payer: UHCCP Medicaid |
$39.42
|
|
|
DEPO MEDROL(METHYLPRE 40MG/1ML
|
Facility
|
IP
|
$112.62
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
63600025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.64 |
| Max. Negotiated Rate |
$108.12 |
| Rate for Payer: Aetna Commercial |
$86.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.84
|
| Rate for Payer: Cash Price |
$56.31
|
| Rate for Payer: Cigna Commercial |
$93.47
|
| Rate for Payer: First Health Commercial |
$106.99
|
| Rate for Payer: Humana Commercial |
$95.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.11
|
| Rate for Payer: Ohio Health Group HMO |
$84.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.91
|
| Rate for Payer: PHCS Commercial |
$108.12
|
| Rate for Payer: United Healthcare All Payer |
$99.11
|
|
|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Professional
|
Both
|
$2.10
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
63600027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna Commercial |
$0.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$2.10
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Healthspan PPO |
$0.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$0.81
|
| Rate for Payer: Multiplan PHCS |
$1.26
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.47
|
| Rate for Payer: UHCCP Medicaid |
$0.74
|
|
|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Facility
|
OP
|
$321.63
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
25002010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$308.76 |
| Rate for Payer: Aetna Commercial |
$247.66
|
| Rate for Payer: Anthem Medicaid |
$110.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.87
|
| Rate for Payer: Cash Price |
$160.82
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: First Health Commercial |
$305.55
|
| Rate for Payer: Humana Commercial |
$273.39
|
| Rate for Payer: Humana KY Medicaid |
$110.61
|
| Rate for Payer: Kentucky WC Medicaid |
$111.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.03
|
| Rate for Payer: Ohio Health Group HMO |
$241.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.71
|
| Rate for Payer: PHCS Commercial |
$308.76
|
| Rate for Payer: United Healthcare All Payer |
$283.03
|
|
|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
63600027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.64
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna Commercial |
$1.74
|
| Rate for Payer: First Health Commercial |
$2.00
|
| Rate for Payer: Humana Commercial |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.85
|
| Rate for Payer: Ohio Health Group HMO |
$1.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.65
|
| Rate for Payer: PHCS Commercial |
$2.02
|
| Rate for Payer: United Healthcare All Payer |
$1.85
|
|
|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
636T0027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.64
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna Commercial |
$1.74
|
| Rate for Payer: First Health Commercial |
$2.00
|
| Rate for Payer: Humana Commercial |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.85
|
| Rate for Payer: Ohio Health Group HMO |
$1.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.65
|
| Rate for Payer: PHCS Commercial |
$2.02
|
| Rate for Payer: United Healthcare All Payer |
$1.85
|
|
