|
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 |
$23.20 |
| 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 |
$61.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.35
|
| 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 |
$24.42 |
| 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 |
$65.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.17
|
| 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 |
$24.42 |
| 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 |
$65.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.17
|
| Rate for Payer: PHCS Commercial |
$78.14
|
| Rate for Payer: United Healthcare All Payer |
$71.63
|
|
|
DEPACON(VALPROATE S 500MG/5ML)
|
Facility
|
OP
|
$124.29
|
|
|
Service Code
|
NDC 143978510
|
| Hospital Charge Code |
25002984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.29 |
| Max. Negotiated Rate |
$119.32 |
| 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
|
| 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 |
$99.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.76
|
| Rate for Payer: PHCS Commercial |
$119.32
|
| Rate for Payer: United Healthcare All Payer |
$109.38
|
|
|
DEPACON(VALPROATE S 500MG/5ML)
|
Facility
|
IP
|
$124.29
|
|
|
Service Code
|
NDC 143978510
|
| Hospital Charge Code |
25002984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.29 |
| 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 |
$99.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.76
|
| Rate for Payer: PHCS Commercial |
$119.32
|
| Rate for Payer: United Healthcare All Payer |
$109.38
|
|
|
DEPAKENE (VALPROATE) 250MG/5ML
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 121067516
|
| Hospital Charge Code |
25000529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
DEPAKENE (VALPROATE) 250MG/5ML
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 121067516
|
| Hospital Charge Code |
25000529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| 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 |
$1.39 |
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| 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 |
$1.39 |
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
DEPAKOTE 500 MG TAB
|
Facility
|
IP
|
$24.45
|
|
|
Service Code
|
NDC 74732713
|
| Hospital Charge Code |
25000532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.33 |
| Max. Negotiated Rate |
$23.47 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.07
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: Cigna Commercial |
$20.29
|
| Rate for Payer: First Health Commercial |
$23.23
|
| Rate for Payer: Humana Commercial |
$20.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.52
|
| Rate for Payer: Ohio Health Group HMO |
$18.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.87
|
| Rate for Payer: PHCS Commercial |
$23.47
|
| Rate for Payer: United Healthcare All Payer |
$21.52
|
|
|
DEPAKOTE 500 MG TAB
|
Facility
|
OP
|
$24.45
|
|
|
Service Code
|
NDC 74732713
|
| Hospital Charge Code |
25000532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.33 |
| Max. Negotiated Rate |
$23.47 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Anthem Medicaid |
$8.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.07
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: Cigna Commercial |
$20.29
|
| Rate for Payer: First Health Commercial |
$23.23
|
| Rate for Payer: Humana Commercial |
$20.78
|
| Rate for Payer: Humana KY Medicaid |
$8.41
|
| Rate for Payer: Kentucky WC Medicaid |
$8.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.52
|
| Rate for Payer: Ohio Health Group HMO |
$18.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.87
|
| Rate for Payer: PHCS Commercial |
$23.47
|
| Rate for Payer: United Healthcare All Payer |
$21.52
|
|
|
DEPAKOTE EC(DIVALPROET)125MG T
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
25000533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$1.49
|
| 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 |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
DEPAKOTE EC(DIVALPROET)125MG T
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
25000533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| 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 |
$1.49
|
| 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 |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| 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 |
$1.33 |
| 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 |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.33 |
| 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 |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
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 |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| 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 |
$1.33 |
| 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 |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.33 |
| 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 |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.43 |
| 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 |
$3.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| 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 |
$1.43 |
| Max. Negotiated Rate |
$4.57 |
| 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
|
| 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 |
$3.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
|
|
DEPLIN 7.5MG TABLET
|
Facility
|
OP
|
$23.59
|
|
|
Service Code
|
NDC 525113990
|
| Hospital Charge Code |
25000537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.08 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Aetna Commercial |
$18.16
|
| Rate for Payer: Anthem Medicaid |
$8.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.40
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Cigna Commercial |
$19.58
|
| Rate for Payer: First Health Commercial |
$22.41
|
| Rate for Payer: Humana Commercial |
$20.05
|
| Rate for Payer: Humana KY Medicaid |
$8.11
|
| Rate for Payer: Kentucky WC Medicaid |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.76
|
| Rate for Payer: Ohio Health Group HMO |
$17.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.28
|
| Rate for Payer: PHCS Commercial |
$22.65
|
| Rate for Payer: United Healthcare All Payer |
$20.76
|
|
|
DEPLIN 7.5MG TABLET
|
Facility
|
IP
|
$23.59
|
|
|
Service Code
|
NDC 525113990
|
| Hospital Charge Code |
25000537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.08 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Aetna Commercial |
$18.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.40
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Cigna Commercial |
$19.58
|
| Rate for Payer: First Health Commercial |
$22.41
|
| Rate for Payer: Humana Commercial |
$20.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.76
|
| Rate for Payer: Ohio Health Group HMO |
$17.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.28
|
| Rate for Payer: PHCS Commercial |
$22.65
|
| Rate for Payer: United Healthcare All Payer |
$20.76
|
|
|
DEPOMEDROL 1MG (40MG SDV)
|
Facility
|
OP
|
$2.92
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
636T0025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Anthem Medicaid |
$1.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna Commercial |
$2.42
|
| Rate for Payer: First Health Commercial |
$2.77
|
| Rate for Payer: Humana Commercial |
$2.48
|
| Rate for Payer: Humana KY Medicaid |
$1.00
|
| Rate for Payer: Humana Medicare Advantage |
$0.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.57
|
| Rate for Payer: Ohio Health Group HMO |
$2.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.01
|
| Rate for Payer: PHCS Commercial |
$2.80
|
| Rate for Payer: United Healthcare All Payer |
$2.57
|
|
|
DEPOMEDROL 1MG (40MG SDV)
|
Facility
|
IP
|
$2.92
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
63600025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.28
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna Commercial |
$2.42
|
| Rate for Payer: First Health Commercial |
$2.77
|
| Rate for Payer: Humana Commercial |
$2.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.57
|
| Rate for Payer: Ohio Health Group HMO |
$2.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.01
|
| Rate for Payer: PHCS Commercial |
$2.80
|
| Rate for Payer: United Healthcare All Payer |
$2.57
|
|
