|
014 THRUWAY WIRE 190CM LT
|
Facility
|
OP
|
$1,524.40
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.17 |
| Max. Negotiated Rate |
$1,463.42 |
| Rate for Payer: Aetna Commercial |
$1,173.79
|
| Rate for Payer: Anthem Medicaid |
$524.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,189.03
|
| Rate for Payer: Cash Price |
$762.20
|
| Rate for Payer: Cigna Commercial |
$1,265.25
|
| Rate for Payer: First Health Commercial |
$1,448.18
|
| Rate for Payer: Humana Commercial |
$1,295.74
|
| Rate for Payer: Humana KY Medicaid |
$524.24
|
| Rate for Payer: Kentucky WC Medicaid |
$529.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,250.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,125.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$457.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,341.47
|
| Rate for Payer: Ohio Health Group HMO |
$1,143.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.56
|
| Rate for Payer: PHCS Commercial |
$1,463.42
|
| Rate for Payer: United Healthcare All Payer |
$1,341.47
|
|
|
014 THRUWAY WIRE 190CM LT
|
Facility
|
IP
|
$1,524.40
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.17 |
| Max. Negotiated Rate |
$1,463.42 |
| Rate for Payer: Aetna Commercial |
$1,173.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,189.03
|
| Rate for Payer: Cash Price |
$762.20
|
| Rate for Payer: Cigna Commercial |
$1,265.25
|
| Rate for Payer: First Health Commercial |
$1,448.18
|
| Rate for Payer: Humana Commercial |
$1,295.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,250.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,125.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$457.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,341.47
|
| Rate for Payer: Ohio Health Group HMO |
$1,143.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.56
|
| Rate for Payer: PHCS Commercial |
$1,463.42
|
| Rate for Payer: United Healthcare All Payer |
$1,341.47
|
|
|
014 THRUWAY WIRE 300CM ST
|
Facility
|
IP
|
$1,787.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$1,716.00 |
| Rate for Payer: Aetna Commercial |
$1,376.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,394.25
|
| Rate for Payer: Cash Price |
$893.75
|
| Rate for Payer: Cigna Commercial |
$1,483.62
|
| Rate for Payer: First Health Commercial |
$1,698.12
|
| Rate for Payer: Humana Commercial |
$1,519.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,465.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,319.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$536.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,573.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,340.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$554.12
|
| Rate for Payer: PHCS Commercial |
$1,716.00
|
| Rate for Payer: United Healthcare All Payer |
$1,573.00
|
|
|
014 THRUWAY WIRE 300CM ST
|
Facility
|
OP
|
$1,787.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$1,716.00 |
| Rate for Payer: Aetna Commercial |
$1,376.38
|
| Rate for Payer: Anthem Medicaid |
$614.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,394.25
|
| Rate for Payer: Cash Price |
$893.75
|
| Rate for Payer: Cigna Commercial |
$1,483.62
|
| Rate for Payer: First Health Commercial |
$1,698.12
|
| Rate for Payer: Humana Commercial |
$1,519.38
|
| Rate for Payer: Humana KY Medicaid |
$614.72
|
| Rate for Payer: Kentucky WC Medicaid |
$620.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,465.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,319.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$536.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$627.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,573.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,340.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$554.12
|
| Rate for Payer: PHCS Commercial |
$1,716.00
|
| Rate for Payer: United Healthcare All Payer |
$1,573.00
|
|
|
.035 260CM FIXED STRAIGHT
|
Facility
|
IP
|
$158.40
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.59 |
| Max. Negotiated Rate |
$152.06 |
| Rate for Payer: Aetna Commercial |
$121.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.55
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$131.47
|
| Rate for Payer: First Health Commercial |
$150.48
|
| Rate for Payer: Humana Commercial |
$134.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.39
|
| Rate for Payer: Ohio Health Group HMO |
$118.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.10
|
| Rate for Payer: PHCS Commercial |
$152.06
|
| Rate for Payer: United Healthcare All Payer |
$139.39
|
|
|
.035 260CM FIXED STRAIGHT
|
Facility
|
OP
|
$158.40
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.59 |
| Max. Negotiated Rate |
$152.06 |
| Rate for Payer: Aetna Commercial |
$121.97
|
| Rate for Payer: Anthem Medicaid |
$54.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.55
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$131.47
|
| Rate for Payer: First Health Commercial |
$150.48
|
| Rate for Payer: Humana Commercial |
$134.64
|
| Rate for Payer: Humana KY Medicaid |
$54.47
|
| Rate for Payer: Kentucky WC Medicaid |
$55.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.39
|
| Rate for Payer: Ohio Health Group HMO |
$118.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.10
|
| Rate for Payer: PHCS Commercial |
$152.06
|
| Rate for Payer: United Healthcare All Payer |
$139.39
|
|
|
.035 FIXED EXCH
|
Facility
|
OP
|
$803.18
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.41 |
| Max. Negotiated Rate |
$771.05 |
| Rate for Payer: Aetna Commercial |
$618.45
|
| Rate for Payer: Anthem Medicaid |
$276.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$626.48
|
| Rate for Payer: Cash Price |
$401.59
|
| Rate for Payer: Cigna Commercial |
$666.64
|
| Rate for Payer: First Health Commercial |
$763.02
|
| Rate for Payer: Humana Commercial |
$682.70
|
| Rate for Payer: Humana KY Medicaid |
$276.21
|
| Rate for Payer: Kentucky WC Medicaid |
$279.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$281.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.80
|
| Rate for Payer: Ohio Health Group HMO |
$602.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.99
|
| Rate for Payer: PHCS Commercial |
$771.05
|
| Rate for Payer: United Healthcare All Payer |
$706.80
|
|
|
.035 FIXED EXCH
|
Facility
|
IP
|
$803.18
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.41 |
| Max. Negotiated Rate |
$771.05 |
| Rate for Payer: Aetna Commercial |
$618.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$626.48
|
| Rate for Payer: Cash Price |
$401.59
|
| Rate for Payer: Cigna Commercial |
$666.64
|
| Rate for Payer: First Health Commercial |
$763.02
|
| Rate for Payer: Humana Commercial |
$682.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.80
|
| Rate for Payer: Ohio Health Group HMO |
$602.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.99
|
| Rate for Payer: PHCS Commercial |
$771.05
|
| Rate for Payer: United Healthcare All Payer |
$706.80
|
|
|
0.45% NACL (LVP) 100ML
|
Facility
|
IP
|
$63.36
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002778
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$60.83 |
| Rate for Payer: Aetna Commercial |
$48.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.42
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cigna Commercial |
$52.59
|
| Rate for Payer: First Health Commercial |
$60.19
|
| Rate for Payer: Humana Commercial |
$53.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.76
|
| Rate for Payer: Ohio Health Group HMO |
$47.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.64
|
| Rate for Payer: PHCS Commercial |
$60.83
|
| Rate for Payer: United Healthcare All Payer |
$55.76
|
|
|
0.45% NACL (LVP) 100ML
|
Facility
|
OP
|
$63.36
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002778
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$60.83 |
| Rate for Payer: Aetna Commercial |
$48.79
|
| Rate for Payer: Anthem Medicaid |
$21.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.42
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cigna Commercial |
$52.59
|
| Rate for Payer: First Health Commercial |
$60.19
|
| Rate for Payer: Humana Commercial |
$53.86
|
| Rate for Payer: Humana KY Medicaid |
$21.79
|
| Rate for Payer: Kentucky WC Medicaid |
$22.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.76
|
| Rate for Payer: Ohio Health Group HMO |
$47.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.64
|
| Rate for Payer: PHCS Commercial |
$60.83
|
| Rate for Payer: United Healthcare All Payer |
$55.76
|
|
|
0.45% NACL (LVP) 250ML
|
Facility
|
OP
|
$69.25
|
|
|
Service Code
|
NDC 990798502
|
| Hospital Charge Code |
25002779
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$66.48 |
| Rate for Payer: Aetna Commercial |
$53.32
|
| Rate for Payer: Anthem Medicaid |
$23.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.02
|
| Rate for Payer: Cash Price |
$34.62
|
| Rate for Payer: Cigna Commercial |
$57.48
|
| Rate for Payer: First Health Commercial |
$65.79
|
| Rate for Payer: Humana Commercial |
$58.86
|
| Rate for Payer: Humana KY Medicaid |
$23.82
|
| Rate for Payer: Kentucky WC Medicaid |
$24.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.94
|
| Rate for Payer: Ohio Health Group HMO |
$51.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.47
|
| Rate for Payer: PHCS Commercial |
$66.48
|
| Rate for Payer: United Healthcare All Payer |
$60.94
|
|
|
0.45% NACL (LVP) 250ML
|
Facility
|
IP
|
$69.25
|
|
|
Service Code
|
NDC 990798502
|
| Hospital Charge Code |
25002779
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$66.48 |
| Rate for Payer: Aetna Commercial |
$53.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.02
|
| Rate for Payer: Cash Price |
$34.62
|
| Rate for Payer: Cigna Commercial |
$57.48
|
| Rate for Payer: First Health Commercial |
$65.79
|
| Rate for Payer: Humana Commercial |
$58.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.94
|
| Rate for Payer: Ohio Health Group HMO |
$51.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.47
|
| Rate for Payer: PHCS Commercial |
$66.48
|
| Rate for Payer: United Healthcare All Payer |
$60.94
|
|
|
0.45% SODIUM CHLORIDE 1000ML
|
Facility
|
OP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem Medicaid |
$32.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Humana KY Medicaid |
$32.41
|
| Rate for Payer: Kentucky WC Medicaid |
$32.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
0.45% SODIUM CHLORIDE 1000ML
|
Facility
|
IP
|
$94.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.52
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna Commercial |
$78.23
|
| Rate for Payer: First Health Commercial |
$89.54
|
| Rate for Payer: Humana Commercial |
$80.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.94
|
| Rate for Payer: Ohio Health Group HMO |
$70.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.22
|
| Rate for Payer: PHCS Commercial |
$90.48
|
| Rate for Payer: United Healthcare All Payer |
$82.94
|
|
|
0.45% SODIUM CHLORIDE 500ML
|
Facility
|
IP
|
$99.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$95.52 |
| Rate for Payer: Aetna Commercial |
$76.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.61
|
| Rate for Payer: Cash Price |
$49.75
|
| Rate for Payer: Cigna Commercial |
$82.58
|
| Rate for Payer: First Health Commercial |
$94.52
|
| Rate for Payer: Humana Commercial |
$84.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.56
|
| Rate for Payer: Ohio Health Group HMO |
$74.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.84
|
| Rate for Payer: PHCS Commercial |
$95.52
|
| Rate for Payer: United Healthcare All Payer |
$87.56
|
|
|
0.45% SODIUM CHLORIDE 500ML
|
Facility
|
OP
|
$99.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$95.52 |
| Rate for Payer: Aetna Commercial |
$76.62
|
| Rate for Payer: Anthem Medicaid |
$34.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.61
|
| Rate for Payer: Cash Price |
$49.75
|
| Rate for Payer: Cigna Commercial |
$82.58
|
| Rate for Payer: First Health Commercial |
$94.52
|
| Rate for Payer: Humana Commercial |
$84.58
|
| Rate for Payer: Humana KY Medicaid |
$34.22
|
| Rate for Payer: Kentucky WC Medicaid |
$34.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.56
|
| Rate for Payer: Ohio Health Group HMO |
$74.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.84
|
| Rate for Payer: PHCS Commercial |
$95.52
|
| Rate for Payer: United Healthcare All Payer |
$87.56
|
|
|
0.45% SODIUM CHLORIDE (RE 30ML
|
Facility
|
IP
|
$78.85
|
|
|
Service Code
|
NDC 990773036
|
| Hospital Charge Code |
25002783
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$75.70 |
| Rate for Payer: Aetna Commercial |
$60.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.50
|
| Rate for Payer: Cash Price |
$39.42
|
| Rate for Payer: Cigna Commercial |
$65.45
|
| Rate for Payer: First Health Commercial |
$74.91
|
| Rate for Payer: Humana Commercial |
$67.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.39
|
| Rate for Payer: Ohio Health Group HMO |
$59.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.44
|
| Rate for Payer: PHCS Commercial |
$75.70
|
| Rate for Payer: United Healthcare All Payer |
$69.39
|
|
|
0.45% SODIUM CHLORIDE (RE 30ML
|
Facility
|
OP
|
$78.85
|
|
|
Service Code
|
NDC 990773036
|
| Hospital Charge Code |
25002783
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$75.70 |
| Rate for Payer: Aetna Commercial |
$60.71
|
| Rate for Payer: Anthem Medicaid |
$27.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.50
|
| Rate for Payer: Cash Price |
$39.42
|
| Rate for Payer: Cigna Commercial |
$65.45
|
| Rate for Payer: First Health Commercial |
$74.91
|
| Rate for Payer: Humana Commercial |
$67.02
|
| Rate for Payer: Humana KY Medicaid |
$27.12
|
| Rate for Payer: Kentucky WC Medicaid |
$27.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.39
|
| Rate for Payer: Ohio Health Group HMO |
$59.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.44
|
| Rate for Payer: PHCS Commercial |
$75.70
|
| Rate for Payer: United Healthcare All Payer |
$69.39
|
|
|
0.9% NACL EXCEL 250ML IV SOLN
|
Facility
|
OP
|
$66.87
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
25003658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$64.20 |
| Rate for Payer: Aetna Commercial |
$51.49
|
| Rate for Payer: Anthem Medicaid |
$23.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.16
|
| Rate for Payer: Cash Price |
$33.44
|
| Rate for Payer: Cigna Commercial |
$55.50
|
| Rate for Payer: First Health Commercial |
$63.53
|
| Rate for Payer: Humana Commercial |
$56.84
|
| Rate for Payer: Humana KY Medicaid |
$23.00
|
| Rate for Payer: Kentucky WC Medicaid |
$23.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.85
|
| Rate for Payer: Ohio Health Group HMO |
$50.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.73
|
| Rate for Payer: PHCS Commercial |
$64.20
|
| Rate for Payer: United Healthcare All Payer |
$58.85
|
|
|
0.9% NACL EXCEL 250ML IV SOLN
|
Facility
|
IP
|
$66.87
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
25003658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$64.20 |
| Rate for Payer: Aetna Commercial |
$51.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.16
|
| Rate for Payer: Cash Price |
$33.44
|
| Rate for Payer: Cigna Commercial |
$55.50
|
| Rate for Payer: First Health Commercial |
$63.53
|
| Rate for Payer: Humana Commercial |
$56.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.85
|
| Rate for Payer: Ohio Health Group HMO |
$50.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.73
|
| Rate for Payer: PHCS Commercial |
$64.20
|
| Rate for Payer: United Healthcare All Payer |
$58.85
|
|
|
0.9% NACL EXCEL 500ML IV SOLN
|
Facility
|
OP
|
$65.08
|
|
| Hospital Charge Code |
63600108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$62.48 |
| Rate for Payer: Aetna Commercial |
$50.11
|
| Rate for Payer: Anthem Medicaid |
$22.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.76
|
| Rate for Payer: Cash Price |
$32.54
|
| Rate for Payer: Cigna Commercial |
$54.02
|
| Rate for Payer: First Health Commercial |
$61.83
|
| Rate for Payer: Humana Commercial |
$55.32
|
| Rate for Payer: Humana KY Medicaid |
$22.38
|
| Rate for Payer: Kentucky WC Medicaid |
$22.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.27
|
| Rate for Payer: Ohio Health Group HMO |
$48.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.17
|
| Rate for Payer: PHCS Commercial |
$62.48
|
| Rate for Payer: United Healthcare All Payer |
$57.27
|
|
|
0.9% NACL EXCEL 500ML IV SOLN
|
Facility
|
IP
|
$65.08
|
|
| Hospital Charge Code |
63600108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$62.48 |
| Rate for Payer: Aetna Commercial |
$50.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.76
|
| Rate for Payer: Cash Price |
$32.54
|
| Rate for Payer: Cigna Commercial |
$54.02
|
| Rate for Payer: First Health Commercial |
$61.83
|
| Rate for Payer: Humana Commercial |
$55.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.27
|
| Rate for Payer: Ohio Health Group HMO |
$48.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.17
|
| Rate for Payer: PHCS Commercial |
$62.48
|
| Rate for Payer: United Healthcare All Payer |
$57.27
|
|
|
0.9% NACL EXCEL 500ML IV SOLN
|
Facility
|
IP
|
$65.08
|
|
| Hospital Charge Code |
636T0108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$62.48 |
| Rate for Payer: Aetna Commercial |
$50.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.76
|
| Rate for Payer: Cash Price |
$32.54
|
| Rate for Payer: Cigna Commercial |
$54.02
|
| Rate for Payer: First Health Commercial |
$61.83
|
| Rate for Payer: Humana Commercial |
$55.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.27
|
| Rate for Payer: Ohio Health Group HMO |
$48.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.17
|
| Rate for Payer: PHCS Commercial |
$62.48
|
| Rate for Payer: United Healthcare All Payer |
$57.27
|
|
|
0.9% NACL EXCEL 500ML IV SOLN
|
Facility
|
IP
|
$67.38
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
25003659
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$64.68 |
| Rate for Payer: Aetna Commercial |
$51.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.56
|
| Rate for Payer: Cash Price |
$33.69
|
| Rate for Payer: Cigna Commercial |
$55.93
|
| Rate for Payer: First Health Commercial |
$64.01
|
| Rate for Payer: Humana Commercial |
$57.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.29
|
| Rate for Payer: Ohio Health Group HMO |
$50.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.89
|
| Rate for Payer: PHCS Commercial |
$64.68
|
| Rate for Payer: United Healthcare All Payer |
$59.29
|
|
|
0.9% NACL EXCEL 500ML IV SOLN
|
Facility
|
OP
|
$65.08
|
|
| Hospital Charge Code |
636T0108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$62.48 |
| Rate for Payer: Aetna Commercial |
$50.11
|
| Rate for Payer: Anthem Medicaid |
$22.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.76
|
| Rate for Payer: Cash Price |
$32.54
|
| Rate for Payer: Cigna Commercial |
$54.02
|
| Rate for Payer: First Health Commercial |
$61.83
|
| Rate for Payer: Humana Commercial |
$55.32
|
| Rate for Payer: Humana KY Medicaid |
$22.38
|
| Rate for Payer: Kentucky WC Medicaid |
$22.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.27
|
| Rate for Payer: Ohio Health Group HMO |
$48.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.17
|
| Rate for Payer: PHCS Commercial |
$62.48
|
| Rate for Payer: United Healthcare All Payer |
$57.27
|
|
