|
SODIUM CHLORIDE IRRIG 250ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990613822
|
| Hospital Charge Code |
25003470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem Medicaid |
$7.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Humana KY Medicaid |
$7.65
|
| Rate for Payer: Kentucky WC Medicaid |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
SODIUM CHLORIDE IRRIG 250ML
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 990613822
|
| Hospital Charge Code |
25003470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
SODIUM CHLORIDE IRRIGAT 1500ML
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 990713836
|
| Hospital Charge Code |
25003467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
SODIUM CHLORIDE IRRIGAT 1500ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990713836
|
| Hospital Charge Code |
25003467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem Medicaid |
$7.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Humana KY Medicaid |
$7.65
|
| Rate for Payer: Kentucky WC Medicaid |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
IP
|
$110.22
|
|
| Hospital Charge Code |
636T0099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.33 |
| Max. Negotiated Rate |
$105.81 |
| Rate for Payer: Aetna Commercial |
$84.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.97
|
| Rate for Payer: Cash Price |
$55.11
|
| Rate for Payer: Cigna Commercial |
$91.48
|
| Rate for Payer: First Health Commercial |
$104.71
|
| Rate for Payer: Humana Commercial |
$93.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$90.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$81.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$96.99
|
| Rate for Payer: Ohio Health Group HMO |
$82.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.17
|
| Rate for Payer: PHCS Commercial |
$105.81
|
| Rate for Payer: United Healthcare All Payer |
$96.99
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
IP
|
$115.22
|
|
|
Service Code
|
NDC 990797208
|
| Hospital Charge Code |
25003469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.98 |
| Max. Negotiated Rate |
$110.61 |
| Rate for Payer: Aetna Commercial |
$88.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.87
|
| Rate for Payer: Cash Price |
$57.61
|
| Rate for Payer: Cigna Commercial |
$95.63
|
| Rate for Payer: First Health Commercial |
$109.46
|
| Rate for Payer: Humana Commercial |
$97.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.39
|
| Rate for Payer: Ohio Health Group HMO |
$86.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.72
|
| Rate for Payer: PHCS Commercial |
$110.61
|
| Rate for Payer: United Healthcare All Payer |
$101.39
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
OP
|
$115.22
|
|
|
Service Code
|
NDC 990797208
|
| Hospital Charge Code |
25003469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.98 |
| Max. Negotiated Rate |
$110.61 |
| Rate for Payer: Aetna Commercial |
$88.72
|
| Rate for Payer: Anthem Medicaid |
$39.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.87
|
| Rate for Payer: Cash Price |
$57.61
|
| Rate for Payer: Cigna Commercial |
$95.63
|
| Rate for Payer: First Health Commercial |
$109.46
|
| Rate for Payer: Humana Commercial |
$97.94
|
| Rate for Payer: Humana KY Medicaid |
$39.62
|
| Rate for Payer: Kentucky WC Medicaid |
$40.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.39
|
| Rate for Payer: Ohio Health Group HMO |
$86.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.72
|
| Rate for Payer: PHCS Commercial |
$110.61
|
| Rate for Payer: United Healthcare All Payer |
$101.39
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
OP
|
$110.22
|
|
| Hospital Charge Code |
636T0099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.33 |
| Max. Negotiated Rate |
$105.81 |
| Rate for Payer: Aetna Commercial |
$84.87
|
| Rate for Payer: Anthem Medicaid |
$37.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.97
|
| Rate for Payer: Cash Price |
$55.11
|
| Rate for Payer: Cigna Commercial |
$91.48
|
| Rate for Payer: First Health Commercial |
$104.71
|
| Rate for Payer: Humana Commercial |
$93.69
|
| Rate for Payer: Humana KY Medicaid |
$37.90
|
| Rate for Payer: Kentucky WC Medicaid |
$38.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$90.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$81.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$96.99
|
| Rate for Payer: Ohio Health Group HMO |
$82.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.17
|
| Rate for Payer: PHCS Commercial |
$105.81
|
| Rate for Payer: United Healthcare All Payer |
$96.99
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
OP
|
$110.22
|
|
| Hospital Charge Code |
63600099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.33 |
| Max. Negotiated Rate |
$105.81 |
| Rate for Payer: Aetna Commercial |
$84.87
|
| Rate for Payer: Anthem Medicaid |
$37.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.97
|
| Rate for Payer: Cash Price |
$55.11
|
| Rate for Payer: Cigna Commercial |
$91.48
|
| Rate for Payer: First Health Commercial |
$104.71
|
| Rate for Payer: Humana Commercial |
$93.69
|
| Rate for Payer: Humana KY Medicaid |
$37.90
|
| Rate for Payer: Kentucky WC Medicaid |
$38.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$90.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$81.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$96.99
|
| Rate for Payer: Ohio Health Group HMO |
$82.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.17
|
| Rate for Payer: PHCS Commercial |
$105.81
|
| Rate for Payer: United Healthcare All Payer |
$96.99
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Professional
|
Both
|
$110.22
|
|
| Hospital Charge Code |
63600099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$110.22 |
| Rate for Payer: Buckeye Medicare Advantage |
$110.22
|
| Rate for Payer: Cash Price |
$55.11
|
| Rate for Payer: Multiplan PHCS |
$66.13
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$77.15
|
| Rate for Payer: UHCCP Medicaid |
$38.58
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
IP
|
$110.22
|
|
| Hospital Charge Code |
63600099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.33 |
| Max. Negotiated Rate |
$105.81 |
| Rate for Payer: Aetna Commercial |
$84.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.97
|
| Rate for Payer: Cash Price |
$55.11
|
| Rate for Payer: Cigna Commercial |
$91.48
|
| Rate for Payer: First Health Commercial |
$104.71
|
| Rate for Payer: Humana Commercial |
$93.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$90.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$81.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$96.99
|
| Rate for Payer: Ohio Health Group HMO |
$82.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.17
|
| Rate for Payer: PHCS Commercial |
$105.81
|
| Rate for Payer: United Healthcare All Payer |
$96.99
|
|
|
SODIUM CHLORIDE TABLE 1GM/1TAB
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 69367022001
|
| Hospital Charge Code |
25001414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
SODIUM CHLORIDE TABLE 1GM/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 69367022001
|
| Hospital Charge Code |
25001414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
SODIUM NITRITE 300MG/10ML
|
Facility
|
IP
|
$544.00
|
|
|
Service Code
|
NDC 60267031110
|
| Hospital Charge Code |
25003872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.72 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.64
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
|
SODIUM NITRITE 300MG/10ML
|
Facility
|
OP
|
$544.00
|
|
|
Service Code
|
NDC 60267031110
|
| Hospital Charge Code |
25003872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.72 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem Medicaid |
$187.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Humana KY Medicaid |
$187.08
|
| Rate for Payer: Kentucky WC Medicaid |
$188.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.64
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
|
SODIUM PHOSPHATE 45MMOL/15ML
|
Facility
|
OP
|
$197.21
|
|
|
Service Code
|
NDC 63323088116
|
| Hospital Charge Code |
25003472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$189.32 |
| Rate for Payer: Aetna Commercial |
$151.85
|
| Rate for Payer: Anthem Medicaid |
$67.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$153.82
|
| Rate for Payer: Cash Price |
$98.61
|
| Rate for Payer: Cigna Commercial |
$163.68
|
| Rate for Payer: First Health Commercial |
$187.35
|
| Rate for Payer: Humana Commercial |
$167.63
|
| Rate for Payer: Humana KY Medicaid |
$67.82
|
| Rate for Payer: Kentucky WC Medicaid |
$68.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$161.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$145.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$173.54
|
| Rate for Payer: Ohio Health Group HMO |
$147.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.14
|
| Rate for Payer: PHCS Commercial |
$189.32
|
| Rate for Payer: United Healthcare All Payer |
$173.54
|
|
|
SODIUM PHOSPHATE 45MMOL/15ML
|
Facility
|
IP
|
$197.21
|
|
|
Service Code
|
NDC 63323088116
|
| Hospital Charge Code |
25003472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$189.32 |
| Rate for Payer: Aetna Commercial |
$151.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$153.82
|
| Rate for Payer: Cash Price |
$98.61
|
| Rate for Payer: Cigna Commercial |
$163.68
|
| Rate for Payer: First Health Commercial |
$187.35
|
| Rate for Payer: Humana Commercial |
$167.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$161.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$145.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$173.54
|
| Rate for Payer: Ohio Health Group HMO |
$147.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.14
|
| Rate for Payer: PHCS Commercial |
$189.32
|
| Rate for Payer: United Healthcare All Payer |
$173.54
|
|
|
SODIUM PHOSPHATES 15mMol SDV
|
Facility
|
OP
|
$87.96
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$84.44 |
| Rate for Payer: Aetna Commercial |
$67.73
|
| Rate for Payer: Anthem Medicaid |
$30.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.61
|
| Rate for Payer: Cash Price |
$43.98
|
| Rate for Payer: Cigna Commercial |
$73.01
|
| Rate for Payer: First Health Commercial |
$83.56
|
| Rate for Payer: Humana Commercial |
$74.77
|
| Rate for Payer: Humana KY Medicaid |
$30.25
|
| Rate for Payer: Kentucky WC Medicaid |
$30.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.40
|
| Rate for Payer: Ohio Health Group HMO |
$65.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.27
|
| Rate for Payer: PHCS Commercial |
$84.44
|
| Rate for Payer: United Healthcare All Payer |
$77.40
|
|
|
SODIUM PHOSPHATES 15mMol SDV
|
Facility
|
IP
|
$87.96
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$84.44 |
| Rate for Payer: Aetna Commercial |
$67.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.61
|
| Rate for Payer: Cash Price |
$43.98
|
| Rate for Payer: Cigna Commercial |
$73.01
|
| Rate for Payer: First Health Commercial |
$83.56
|
| Rate for Payer: Humana Commercial |
$74.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.40
|
| Rate for Payer: Ohio Health Group HMO |
$65.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.27
|
| Rate for Payer: PHCS Commercial |
$84.44
|
| Rate for Payer: United Healthcare All Payer |
$77.40
|
|
|
SODIUM POLYSTYRENE S 15GM/60ML
|
Facility
|
OP
|
$41.80
|
|
|
Service Code
|
NDC 46287000660
|
| Hospital Charge Code |
25001417
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Aetna Commercial |
$32.19
|
| Rate for Payer: Anthem Medicaid |
$14.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.60
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cigna Commercial |
$34.69
|
| Rate for Payer: First Health Commercial |
$39.71
|
| Rate for Payer: Humana Commercial |
$35.53
|
| Rate for Payer: Humana KY Medicaid |
$14.38
|
| Rate for Payer: Kentucky WC Medicaid |
$14.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$36.78
|
| Rate for Payer: Ohio Health Group HMO |
$31.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.96
|
| Rate for Payer: PHCS Commercial |
$40.13
|
| Rate for Payer: United Healthcare All Payer |
$36.78
|
|
|
SODIUM POLYSTYRENE S 15GM/60ML
|
Facility
|
IP
|
$41.80
|
|
|
Service Code
|
NDC 46287000660
|
| Hospital Charge Code |
25001417
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Aetna Commercial |
$32.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.60
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cigna Commercial |
$34.69
|
| Rate for Payer: First Health Commercial |
$39.71
|
| Rate for Payer: Humana Commercial |
$35.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$36.78
|
| Rate for Payer: Ohio Health Group HMO |
$31.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.96
|
| Rate for Payer: PHCS Commercial |
$40.13
|
| Rate for Payer: United Healthcare All Payer |
$36.78
|
|
|
SODIUM THIOSULFATE 25% VL(50ML
|
Facility
|
IP
|
$544.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.72 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.64
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
|
SODIUM THIOSULFATE 25% VL(50ML
|
Facility
|
OP
|
$544.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.72 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem Medicaid |
$187.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Humana KY Medicaid |
$187.08
|
| Rate for Payer: Kentucky WC Medicaid |
$188.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.64
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
|
SOD POLYSTYRENE SULF 15GM PWDR
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
NDC 10702003615
|
| Hospital Charge Code |
25003473
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.86 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.82
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
SOD POLYSTYRENE SULF 15GM PWDR
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
NDC 10702003615
|
| Hospital Charge Code |
25003473
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.86 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem Medicaid |
$41.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Humana KY Medicaid |
$41.96
|
| Rate for Payer: Kentucky WC Medicaid |
$42.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.82
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
