|
SAME DAY NB DISCHARGE
|
Facility
|
IP
|
$379.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
51000119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$113.70 |
| Max. Negotiated Rate |
$363.84 |
| Rate for Payer: Aetna Commercial |
$291.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$295.62
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cigna Commercial |
$314.57
|
| Rate for Payer: First Health Commercial |
$360.05
|
| Rate for Payer: Humana Commercial |
$322.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$310.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$279.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$333.52
|
| Rate for Payer: Ohio Health Group HMO |
$284.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$303.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$329.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.51
|
| Rate for Payer: PHCS Commercial |
$363.84
|
| Rate for Payer: United Healthcare All Payer |
$333.52
|
|
|
SAME DAY NB DISCHARGE
|
Professional
|
Both
|
$379.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
51000119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.12 |
| Max. Negotiated Rate |
$227.40 |
| Rate for Payer: Aetna Commercial |
$119.25
|
| Rate for Payer: Ambetter Exchange |
$101.35
|
| Rate for Payer: Anthem Medicaid |
$61.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$101.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$101.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$121.62
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: Healthspan PPO |
$88.64
|
| Rate for Payer: Humana Medicaid |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$101.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.34
|
| Rate for Payer: Molina Healthcare Passport |
$61.12
|
| Rate for Payer: Multiplan PHCS |
$227.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$131.75
|
| Rate for Payer: UHCCP Medicaid |
$132.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$101.35
|
|
|
SAME DAY NB DISCHARGE
|
Facility
|
OP
|
$379.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
51000119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$363.84 |
| Rate for Payer: Aetna Commercial |
$291.83
|
| Rate for Payer: Anthem Medicaid |
$130.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$295.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cigna Commercial |
$314.57
|
| Rate for Payer: First Health Commercial |
$360.05
|
| Rate for Payer: Humana Commercial |
$322.15
|
| Rate for Payer: Humana KY Medicaid |
$130.34
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$131.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$310.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$279.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$132.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$333.52
|
| Rate for Payer: Ohio Health Group HMO |
$284.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$303.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$329.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.51
|
| Rate for Payer: PHCS Commercial |
$363.84
|
| Rate for Payer: United Healthcare All Payer |
$333.52
|
|
|
SAME DAY NB DISCHARGE(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
510P0119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.12 |
| Max. Negotiated Rate |
$131.75 |
| Rate for Payer: Aetna Commercial |
$119.25
|
| Rate for Payer: Ambetter Exchange |
$101.35
|
| Rate for Payer: Anthem Medicaid |
$61.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$101.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$101.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$121.62
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: Healthspan PPO |
$88.64
|
| Rate for Payer: Humana Medicaid |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$101.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.34
|
| Rate for Payer: Molina Healthcare Passport |
$61.12
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$131.75
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$101.35
|
|
|
SAME DAY NB DISCHARGE(T
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
510T0119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.56 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem Medicaid |
$61.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Humana KY Medicaid |
$61.56
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$62.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
SAME DAY NB DISCHARGE(T
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
510T0119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
SAMSCA 15MG TABLET
|
Facility
|
OP
|
$690.20
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
25001363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.06 |
| Max. Negotiated Rate |
$662.59 |
| Rate for Payer: Aetna Commercial |
$531.45
|
| Rate for Payer: Anthem Medicaid |
$237.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.36
|
| Rate for Payer: Cash Price |
$345.10
|
| Rate for Payer: Cigna Commercial |
$572.87
|
| Rate for Payer: First Health Commercial |
$655.69
|
| Rate for Payer: Humana Commercial |
$586.67
|
| Rate for Payer: Humana KY Medicaid |
$237.36
|
| Rate for Payer: Kentucky WC Medicaid |
$239.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.38
|
| Rate for Payer: Ohio Health Group HMO |
$517.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$552.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$600.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$476.24
|
| Rate for Payer: PHCS Commercial |
$662.59
|
| Rate for Payer: United Healthcare All Payer |
$607.38
|
|
|
SAMSCA 15MG TABLET
|
Facility
|
IP
|
$690.20
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
25001363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.06 |
| Max. Negotiated Rate |
$662.59 |
| Rate for Payer: Aetna Commercial |
$531.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.36
|
| Rate for Payer: Cash Price |
$345.10
|
| Rate for Payer: Cigna Commercial |
$572.87
|
| Rate for Payer: First Health Commercial |
$655.69
|
| Rate for Payer: Humana Commercial |
$586.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.38
|
| Rate for Payer: Ohio Health Group HMO |
$517.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$552.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$600.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$476.24
|
| Rate for Payer: PHCS Commercial |
$662.59
|
| Rate for Payer: United Healthcare All Payer |
$607.38
|
|
|
SAMSCA 30 MG TABLET
|
Facility
|
OP
|
$709.64
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
25001364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$212.89 |
| Max. Negotiated Rate |
$681.25 |
| Rate for Payer: Aetna Commercial |
$546.42
|
| Rate for Payer: Anthem Medicaid |
$244.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$553.52
|
| Rate for Payer: Cash Price |
$354.82
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: First Health Commercial |
$674.16
|
| Rate for Payer: Humana Commercial |
$603.19
|
| Rate for Payer: Humana KY Medicaid |
$244.05
|
| Rate for Payer: Kentucky WC Medicaid |
$246.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$581.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$523.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$212.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$248.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$624.48
|
| Rate for Payer: Ohio Health Group HMO |
$532.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$567.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$617.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$489.65
|
| Rate for Payer: PHCS Commercial |
$681.25
|
| Rate for Payer: United Healthcare All Payer |
$624.48
|
|
|
SAMSCA 30 MG TABLET
|
Facility
|
IP
|
$709.64
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
25001364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$212.89 |
| Max. Negotiated Rate |
$681.25 |
| Rate for Payer: Aetna Commercial |
$546.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$553.52
|
| Rate for Payer: Cash Price |
$354.82
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: First Health Commercial |
$674.16
|
| Rate for Payer: Humana Commercial |
$603.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$581.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$523.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$212.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$624.48
|
| Rate for Payer: Ohio Health Group HMO |
$532.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$567.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$617.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$489.65
|
| Rate for Payer: PHCS Commercial |
$681.25
|
| Rate for Payer: United Healthcare All Payer |
$624.48
|
|
|
SANDOSTATIN 25MCG 100MCG/1ML V
|
Facility
|
IP
|
$54.17
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial |
$41.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.25
|
| Rate for Payer: Cash Price |
$27.09
|
| Rate for Payer: Cigna Commercial |
$44.96
|
| Rate for Payer: First Health Commercial |
$51.46
|
| Rate for Payer: Humana Commercial |
$46.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.67
|
| Rate for Payer: Ohio Health Group HMO |
$40.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.38
|
| Rate for Payer: PHCS Commercial |
$52.00
|
| Rate for Payer: United Healthcare All Payer |
$47.67
|
|
|
SANDOSTATIN 25MCG 100MCG/1ML V
|
Facility
|
OP
|
$54.17
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial |
$41.71
|
| Rate for Payer: Anthem Medicaid |
$18.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.25
|
| Rate for Payer: Cash Price |
$27.09
|
| Rate for Payer: Cigna Commercial |
$44.96
|
| Rate for Payer: First Health Commercial |
$51.46
|
| Rate for Payer: Humana Commercial |
$46.04
|
| Rate for Payer: Humana KY Medicaid |
$18.63
|
| Rate for Payer: Kentucky WC Medicaid |
$18.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.67
|
| Rate for Payer: Ohio Health Group HMO |
$40.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.38
|
| Rate for Payer: PHCS Commercial |
$52.00
|
| Rate for Payer: United Healthcare All Payer |
$47.67
|
|
|
SANDOSTATIN25MCG 500MCG 1MLAMP
|
Facility
|
OP
|
$205.69
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.71 |
| Max. Negotiated Rate |
$197.46 |
| Rate for Payer: Aetna Commercial |
$158.38
|
| Rate for Payer: Anthem Medicaid |
$70.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.44
|
| Rate for Payer: Cash Price |
$102.84
|
| Rate for Payer: Cigna Commercial |
$170.72
|
| Rate for Payer: First Health Commercial |
$195.41
|
| Rate for Payer: Humana Commercial |
$174.84
|
| Rate for Payer: Humana KY Medicaid |
$70.74
|
| Rate for Payer: Kentucky WC Medicaid |
$71.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.01
|
| Rate for Payer: Ohio Health Group HMO |
$154.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$164.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.93
|
| Rate for Payer: PHCS Commercial |
$197.46
|
| Rate for Payer: United Healthcare All Payer |
$181.01
|
|
|
SANDOSTATIN25MCG 500MCG 1MLAMP
|
Facility
|
IP
|
$205.69
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.71 |
| Max. Negotiated Rate |
$197.46 |
| Rate for Payer: Aetna Commercial |
$158.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.44
|
| Rate for Payer: Cash Price |
$102.84
|
| Rate for Payer: Cigna Commercial |
$170.72
|
| Rate for Payer: First Health Commercial |
$195.41
|
| Rate for Payer: Humana Commercial |
$174.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.01
|
| Rate for Payer: Ohio Health Group HMO |
$154.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$164.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.93
|
| Rate for Payer: PHCS Commercial |
$197.46
|
| Rate for Payer: United Healthcare All Payer |
$181.01
|
|
|
SANDOSTATINLAR 1MG 20MG DEPKIT
|
Facility
|
OP
|
$25,158.84
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.20 |
| Max. Negotiated Rate |
$24,152.49 |
| Rate for Payer: Aetna Commercial |
$19,372.31
|
| Rate for Payer: Anthem Medicaid |
$8,652.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$212.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,623.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$297.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.47
|
| Rate for Payer: Cash Price |
$12,579.42
|
| Rate for Payer: Cash Price |
$12,579.42
|
| Rate for Payer: Cigna Commercial |
$20,881.84
|
| Rate for Payer: First Health Commercial |
$23,900.90
|
| Rate for Payer: Humana Commercial |
$21,385.01
|
| Rate for Payer: Humana KY Medicaid |
$8,652.13
|
| Rate for Payer: Humana Medicare Advantage |
$212.20
|
| Rate for Payer: Kentucky WC Medicaid |
$8,740.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,630.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,567.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,825.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,139.78
|
| Rate for Payer: Ohio Health Group HMO |
$18,869.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,127.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,888.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,359.60
|
| Rate for Payer: PHCS Commercial |
$24,152.49
|
| Rate for Payer: United Healthcare All Payer |
$22,139.78
|
|
|
SANDOSTATINLAR 1MG 20MG DEPKIT
|
Facility
|
IP
|
$25,158.84
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,547.65 |
| Max. Negotiated Rate |
$24,152.49 |
| Rate for Payer: Aetna Commercial |
$19,372.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,623.90
|
| Rate for Payer: Cash Price |
$12,579.42
|
| Rate for Payer: Cigna Commercial |
$20,881.84
|
| Rate for Payer: First Health Commercial |
$23,900.90
|
| Rate for Payer: Humana Commercial |
$21,385.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,630.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,567.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,547.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,139.78
|
| Rate for Payer: Ohio Health Group HMO |
$18,869.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,127.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,888.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,359.60
|
| Rate for Payer: PHCS Commercial |
$24,152.49
|
| Rate for Payer: United Healthcare All Payer |
$22,139.78
|
|
|
SANDOSTATINLAR 1MG 30MG DEPKIT
|
Facility
|
OP
|
$37,673.45
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002264
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.20 |
| Max. Negotiated Rate |
$36,166.51 |
| Rate for Payer: Aetna Commercial |
$29,008.56
|
| Rate for Payer: Anthem Medicaid |
$12,955.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$212.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,385.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$297.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.47
|
| Rate for Payer: Cash Price |
$18,836.72
|
| Rate for Payer: Cash Price |
$18,836.72
|
| Rate for Payer: Cigna Commercial |
$31,268.96
|
| Rate for Payer: First Health Commercial |
$35,789.78
|
| Rate for Payer: Humana Commercial |
$32,022.43
|
| Rate for Payer: Humana KY Medicaid |
$12,955.90
|
| Rate for Payer: Humana Medicare Advantage |
$212.20
|
| Rate for Payer: Kentucky WC Medicaid |
$13,087.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,892.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,803.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,215.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,152.64
|
| Rate for Payer: Ohio Health Group HMO |
$28,255.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30,138.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32,775.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,994.68
|
| Rate for Payer: PHCS Commercial |
$36,166.51
|
| Rate for Payer: United Healthcare All Payer |
$33,152.64
|
|
|
SANDOSTATINLAR 1MG 30MG DEPKIT
|
Facility
|
IP
|
$37,673.45
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002264
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,302.03 |
| Max. Negotiated Rate |
$36,166.51 |
| Rate for Payer: Aetna Commercial |
$29,008.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,385.29
|
| Rate for Payer: Cash Price |
$18,836.72
|
| Rate for Payer: Cigna Commercial |
$31,268.96
|
| Rate for Payer: First Health Commercial |
$35,789.78
|
| Rate for Payer: Humana Commercial |
$32,022.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,892.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,803.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,302.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,152.64
|
| Rate for Payer: Ohio Health Group HMO |
$28,255.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30,138.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32,775.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,994.68
|
| Rate for Payer: PHCS Commercial |
$36,166.51
|
| Rate for Payer: United Healthcare All Payer |
$33,152.64
|
|
|
SANE EXAM
|
Facility
|
OP
|
$706.00
|
|
| Hospital Charge Code |
92900001
|
|
Hospital Revenue Code
|
929
|
| Min. Negotiated Rate |
$211.80 |
| Max. Negotiated Rate |
$677.76 |
| Rate for Payer: Aetna Commercial |
$543.62
|
| Rate for Payer: Anthem Medicaid |
$242.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$550.68
|
| Rate for Payer: Cash Price |
$353.00
|
| Rate for Payer: Cigna Commercial |
$585.98
|
| Rate for Payer: First Health Commercial |
$670.70
|
| Rate for Payer: Humana Commercial |
$600.10
|
| Rate for Payer: Humana KY Medicaid |
$242.79
|
| Rate for Payer: Kentucky WC Medicaid |
$245.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$578.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$521.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$211.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$247.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$621.28
|
| Rate for Payer: Ohio Health Group HMO |
$529.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$564.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$487.14
|
| Rate for Payer: PHCS Commercial |
$677.76
|
| Rate for Payer: United Healthcare All Payer |
$621.28
|
|
|
SANE EXAM
|
Facility
|
IP
|
$706.00
|
|
| Hospital Charge Code |
92900001
|
|
Hospital Revenue Code
|
929
|
| Min. Negotiated Rate |
$211.80 |
| Max. Negotiated Rate |
$677.76 |
| Rate for Payer: Aetna Commercial |
$543.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$550.68
|
| Rate for Payer: Cash Price |
$353.00
|
| Rate for Payer: Cigna Commercial |
$585.98
|
| Rate for Payer: First Health Commercial |
$670.70
|
| Rate for Payer: Humana Commercial |
$600.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$578.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$521.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$211.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$621.28
|
| Rate for Payer: Ohio Health Group HMO |
$529.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$564.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$487.14
|
| Rate for Payer: PHCS Commercial |
$677.76
|
| Rate for Payer: United Healthcare All Payer |
$621.28
|
|
|
SANTYL (COLLAGENASE) OINT 30GM
|
Facility
|
IP
|
$30.75
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
25001367
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$29.52 |
| Rate for Payer: Aetna Commercial |
$23.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.98
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cigna Commercial |
$25.52
|
| Rate for Payer: First Health Commercial |
$29.21
|
| Rate for Payer: Humana Commercial |
$26.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.06
|
| Rate for Payer: Ohio Health Group HMO |
$23.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.22
|
| Rate for Payer: PHCS Commercial |
$29.52
|
| Rate for Payer: United Healthcare All Payer |
$27.06
|
|
|
SANTYL (COLLAGENASE) OINT 30GM
|
Facility
|
OP
|
$30.75
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
25001367
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$29.52 |
| Rate for Payer: Aetna Commercial |
$23.68
|
| Rate for Payer: Anthem Medicaid |
$10.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.98
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cigna Commercial |
$25.52
|
| Rate for Payer: First Health Commercial |
$29.21
|
| Rate for Payer: Humana Commercial |
$26.14
|
| Rate for Payer: Humana KY Medicaid |
$10.57
|
| Rate for Payer: Kentucky WC Medicaid |
$10.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.06
|
| Rate for Payer: Ohio Health Group HMO |
$23.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.22
|
| Rate for Payer: PHCS Commercial |
$29.52
|
| Rate for Payer: United Healthcare All Payer |
$27.06
|
|
|
SAPHNELO 1MG (300mg SDV)
|
Facility
|
OP
|
$29,070.08
|
|
|
Service Code
|
HCPCS J0491
|
| Hospital Charge Code |
25004351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$27,907.28 |
| Rate for Payer: Aetna Commercial |
$22,383.96
|
| Rate for Payer: Anthem Medicaid |
$9,997.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,674.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.43
|
| Rate for Payer: Cash Price |
$14,535.04
|
| Rate for Payer: Cash Price |
$14,535.04
|
| Rate for Payer: Cigna Commercial |
$24,128.17
|
| Rate for Payer: First Health Commercial |
$27,616.58
|
| Rate for Payer: Humana Commercial |
$24,709.57
|
| Rate for Payer: Humana KY Medicaid |
$9,997.20
|
| Rate for Payer: Humana Medicare Advantage |
$18.10
|
| Rate for Payer: Kentucky WC Medicaid |
$10,098.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,837.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,453.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,197.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,581.67
|
| Rate for Payer: Ohio Health Group HMO |
$21,802.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,256.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,290.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,058.36
|
| Rate for Payer: PHCS Commercial |
$27,907.28
|
| Rate for Payer: United Healthcare All Payer |
$25,581.67
|
|
|
SAPHNELO 1MG (300mg SDV)
|
Facility
|
IP
|
$29,070.08
|
|
|
Service Code
|
HCPCS J0491
|
| Hospital Charge Code |
25004351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,721.02 |
| Max. Negotiated Rate |
$27,907.28 |
| Rate for Payer: Aetna Commercial |
$22,383.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,674.66
|
| Rate for Payer: Cash Price |
$14,535.04
|
| Rate for Payer: Cigna Commercial |
$24,128.17
|
| Rate for Payer: First Health Commercial |
$27,616.58
|
| Rate for Payer: Humana Commercial |
$24,709.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,837.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,453.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,721.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,581.67
|
| Rate for Payer: Ohio Health Group HMO |
$21,802.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,256.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,290.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,058.36
|
| Rate for Payer: PHCS Commercial |
$27,907.28
|
| Rate for Payer: United Healthcare All Payer |
$25,581.67
|
|
|
SAPPHIRE II PRO OTW 1.00*10
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem Medicaid |
$708.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Humana KY Medicaid |
$708.43
|
| Rate for Payer: Kentucky WC Medicaid |
$715.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
