|
SOTALOL 1mg (150mg SDV)
|
Facility
|
IP
|
$17,963.20
|
|
|
Service Code
|
HCPCS C9482
|
| Hospital Charge Code |
25004195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,335.22 |
| Max. Negotiated Rate |
$17,244.67 |
| Rate for Payer: Aetna Commercial |
$13,831.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,011.30
|
| Rate for Payer: Cash Price |
$8,981.60
|
| Rate for Payer: Cigna Commercial |
$14,909.46
|
| Rate for Payer: First Health Commercial |
$17,065.04
|
| Rate for Payer: Humana Commercial |
$15,268.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,729.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,256.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,388.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,807.62
|
| Rate for Payer: Ohio Health Group HMO |
$13,472.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,592.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,335.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,568.59
|
| Rate for Payer: PHCS Commercial |
$17,244.67
|
| Rate for Payer: United Healthcare All Payer |
$15,807.62
|
|
|
SOTALOL 1mg (150mg SDV)
|
Facility
|
OP
|
$17,963.20
|
|
|
Service Code
|
HCPCS C9482
|
| Hospital Charge Code |
25004195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.71 |
| Max. Negotiated Rate |
$17,244.67 |
| Rate for Payer: Aetna Commercial |
$13,831.66
|
| Rate for Payer: Anthem Medicaid |
$6,177.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,011.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.96
|
| Rate for Payer: Cash Price |
$8,981.60
|
| Rate for Payer: Cash Price |
$8,981.60
|
| Rate for Payer: Cigna Commercial |
$14,909.46
|
| Rate for Payer: First Health Commercial |
$17,065.04
|
| Rate for Payer: Humana Commercial |
$15,268.72
|
| Rate for Payer: Humana KY Medicaid |
$6,177.54
|
| Rate for Payer: Humana Medicare Advantage |
$20.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,240.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,729.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,256.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,301.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,807.62
|
| Rate for Payer: Ohio Health Group HMO |
$13,472.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,592.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,335.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,568.59
|
| Rate for Payer: PHCS Commercial |
$17,244.67
|
| Rate for Payer: United Healthcare All Payer |
$15,807.62
|
|
|
SOTALOL 40MG/8ML ORAL LIQUID
|
Facility
|
OP
|
$32.70
|
|
|
Service Code
|
NDC 24338053025
|
| Hospital Charge Code |
25004391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$31.39 |
| Rate for Payer: Aetna Commercial |
$25.18
|
| Rate for Payer: Anthem Medicaid |
$11.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.51
|
| Rate for Payer: Cash Price |
$16.35
|
| Rate for Payer: Cigna Commercial |
$27.14
|
| Rate for Payer: First Health Commercial |
$31.06
|
| Rate for Payer: Humana Commercial |
$27.80
|
| Rate for Payer: Humana KY Medicaid |
$11.25
|
| Rate for Payer: Kentucky WC Medicaid |
$11.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.78
|
| Rate for Payer: Ohio Health Group HMO |
$24.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.14
|
| Rate for Payer: PHCS Commercial |
$31.39
|
| Rate for Payer: United Healthcare All Payer |
$28.78
|
|
|
SOTALOL 40MG/8ML ORAL LIQUID
|
Facility
|
IP
|
$32.70
|
|
|
Service Code
|
NDC 24338053025
|
| Hospital Charge Code |
25004391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$31.39 |
| Rate for Payer: Aetna Commercial |
$25.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.51
|
| Rate for Payer: Cash Price |
$16.35
|
| Rate for Payer: Cigna Commercial |
$27.14
|
| Rate for Payer: First Health Commercial |
$31.06
|
| Rate for Payer: Humana Commercial |
$27.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.78
|
| Rate for Payer: Ohio Health Group HMO |
$24.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.14
|
| Rate for Payer: PHCS Commercial |
$31.39
|
| Rate for Payer: United Healthcare All Payer |
$28.78
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
IP
|
$410.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$393.77 |
| Rate for Payer: Aetna Commercial |
$315.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$319.94
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cigna Commercial |
$340.45
|
| Rate for Payer: First Health Commercial |
$389.67
|
| Rate for Payer: Humana Commercial |
$348.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$336.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$302.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$360.96
|
| Rate for Payer: Ohio Health Group HMO |
$307.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.16
|
| Rate for Payer: PHCS Commercial |
$393.77
|
| Rate for Payer: United Healthcare All Payer |
$360.96
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
OP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.36 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem Medicaid |
$146.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Humana KY Medicaid |
$146.44
|
| Rate for Payer: Kentucky WC Medicaid |
$147.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$85.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.00
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
IP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.36 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$85.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.00
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
OP
|
$410.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$393.77 |
| Rate for Payer: Aetna Commercial |
$315.84
|
| Rate for Payer: Anthem Medicaid |
$141.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$319.94
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cigna Commercial |
$340.45
|
| Rate for Payer: First Health Commercial |
$389.67
|
| Rate for Payer: Humana Commercial |
$348.65
|
| Rate for Payer: Humana KY Medicaid |
$141.06
|
| Rate for Payer: Kentucky WC Medicaid |
$142.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$336.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$302.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$143.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$360.96
|
| Rate for Payer: Ohio Health Group HMO |
$307.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.16
|
| Rate for Payer: PHCS Commercial |
$393.77
|
| Rate for Payer: United Healthcare All Payer |
$360.96
|
|
|
SOTRADECOL 1% 2mL MDV
|
Professional
|
Both
|
$410.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$410.18 |
| Rate for Payer: Buckeye Medicare Advantage |
$410.18
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$246.11
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$287.13
|
| Rate for Payer: UHCCP Medicaid |
$143.56
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
OP
|
$410.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$393.77 |
| Rate for Payer: Aetna Commercial |
$315.84
|
| Rate for Payer: Anthem Medicaid |
$141.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$319.94
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cigna Commercial |
$340.45
|
| Rate for Payer: First Health Commercial |
$389.67
|
| Rate for Payer: Humana Commercial |
$348.65
|
| Rate for Payer: Humana KY Medicaid |
$141.06
|
| Rate for Payer: Kentucky WC Medicaid |
$142.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$336.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$302.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$143.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$360.96
|
| Rate for Payer: Ohio Health Group HMO |
$307.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.16
|
| Rate for Payer: PHCS Commercial |
$393.77
|
| Rate for Payer: United Healthcare All Payer |
$360.96
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
IP
|
$410.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$393.77 |
| Rate for Payer: Aetna Commercial |
$315.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$319.94
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cigna Commercial |
$340.45
|
| Rate for Payer: First Health Commercial |
$389.67
|
| Rate for Payer: Humana Commercial |
$348.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$336.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$302.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$360.96
|
| Rate for Payer: Ohio Health Group HMO |
$307.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.16
|
| Rate for Payer: PHCS Commercial |
$393.77
|
| Rate for Payer: United Healthcare All Payer |
$360.96
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
IP
|
$202.13
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$194.04 |
| Rate for Payer: Aetna Commercial |
$155.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.66
|
| Rate for Payer: Cash Price |
$101.06
|
| Rate for Payer: Cigna Commercial |
$167.77
|
| Rate for Payer: First Health Commercial |
$192.02
|
| Rate for Payer: Humana Commercial |
$171.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$165.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$177.87
|
| Rate for Payer: Ohio Health Group HMO |
$151.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.66
|
| Rate for Payer: PHCS Commercial |
$194.04
|
| Rate for Payer: United Healthcare All Payer |
$177.87
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
IP
|
$202.13
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$194.04 |
| Rate for Payer: Aetna Commercial |
$155.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.66
|
| Rate for Payer: Cash Price |
$101.06
|
| Rate for Payer: Cigna Commercial |
$167.77
|
| Rate for Payer: First Health Commercial |
$192.02
|
| Rate for Payer: Humana Commercial |
$171.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$165.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$177.87
|
| Rate for Payer: Ohio Health Group HMO |
$151.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.66
|
| Rate for Payer: PHCS Commercial |
$194.04
|
| Rate for Payer: United Healthcare All Payer |
$177.87
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
IP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.55 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.09
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
OP
|
$202.13
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$194.04 |
| Rate for Payer: Aetna Commercial |
$155.64
|
| Rate for Payer: Anthem Medicaid |
$69.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.66
|
| Rate for Payer: Cash Price |
$101.06
|
| Rate for Payer: Cigna Commercial |
$167.77
|
| Rate for Payer: First Health Commercial |
$192.02
|
| Rate for Payer: Humana Commercial |
$171.81
|
| Rate for Payer: Humana KY Medicaid |
$69.51
|
| Rate for Payer: Kentucky WC Medicaid |
$70.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$165.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$177.87
|
| Rate for Payer: Ohio Health Group HMO |
$151.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.66
|
| Rate for Payer: PHCS Commercial |
$194.04
|
| Rate for Payer: United Healthcare All Payer |
$177.87
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
OP
|
$202.13
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$194.04 |
| Rate for Payer: Aetna Commercial |
$155.64
|
| Rate for Payer: Anthem Medicaid |
$69.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.66
|
| Rate for Payer: Cash Price |
$101.06
|
| Rate for Payer: Cigna Commercial |
$167.77
|
| Rate for Payer: First Health Commercial |
$192.02
|
| Rate for Payer: Humana Commercial |
$171.81
|
| Rate for Payer: Humana KY Medicaid |
$69.51
|
| Rate for Payer: Kentucky WC Medicaid |
$70.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$165.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$177.87
|
| Rate for Payer: Ohio Health Group HMO |
$151.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.66
|
| Rate for Payer: PHCS Commercial |
$194.04
|
| Rate for Payer: United Healthcare All Payer |
$177.87
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Professional
|
Both
|
$202.13
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$202.13 |
| Rate for Payer: Buckeye Medicare Advantage |
$202.13
|
| Rate for Payer: Cash Price |
$101.06
|
| Rate for Payer: Cash Price |
$101.06
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$121.28
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$141.49
|
| Rate for Payer: UHCCP Medicaid |
$70.75
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
OP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.55 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem Medicaid |
$144.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Humana KY Medicaid |
$144.32
|
| Rate for Payer: Kentucky WC Medicaid |
$145.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.09
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
Sotrovimab infusion and monito
|
Facility
|
IP
|
$801.00
|
|
|
Service Code
|
HCPCS M0247
|
| Hospital Charge Code |
77000071
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
Sotrovimab infusion and monito
|
Facility
|
OP
|
$801.00
|
|
|
Service Code
|
HCPCS M0247
|
| Hospital Charge Code |
77000071
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem Medicaid |
$275.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$572.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$551.97
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Humana KY Medicaid |
$275.46
|
| Rate for Payer: Humana Medicare Advantage |
$408.87
|
| Rate for Payer: Kentucky WC Medicaid |
$278.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$490.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
SOYBEAN IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000873
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SOYBEAN IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000873
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SPACEOAR VUE SYSTEM
|
Facility
|
IP
|
$20,316.15
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,641.10 |
| Max. Negotiated Rate |
$19,503.50 |
| Rate for Payer: Aetna Commercial |
$15,643.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,846.60
|
| Rate for Payer: Cash Price |
$10,158.08
|
| Rate for Payer: Cigna Commercial |
$16,862.40
|
| Rate for Payer: First Health Commercial |
$19,300.34
|
| Rate for Payer: Humana Commercial |
$17,268.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,659.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,993.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,094.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,878.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,237.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,063.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,641.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,298.01
|
| Rate for Payer: PHCS Commercial |
$19,503.50
|
| Rate for Payer: United Healthcare All Payer |
$17,878.21
|
|
|
SPACEOAR VUE SYSTEM
|
Facility
|
OP
|
$20,316.15
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,641.10 |
| Max. Negotiated Rate |
$19,503.50 |
| Rate for Payer: Aetna Commercial |
$15,643.44
|
| Rate for Payer: Anthem Medicaid |
$6,986.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,846.60
|
| Rate for Payer: Cash Price |
$10,158.08
|
| Rate for Payer: Cigna Commercial |
$16,862.40
|
| Rate for Payer: First Health Commercial |
$19,300.34
|
| Rate for Payer: Humana Commercial |
$17,268.73
|
| Rate for Payer: Humana KY Medicaid |
$6,986.72
|
| Rate for Payer: Kentucky WC Medicaid |
$7,057.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,659.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,993.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,094.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,126.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,878.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,237.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,063.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,641.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,298.01
|
| Rate for Payer: PHCS Commercial |
$19,503.50
|
| Rate for Payer: United Healthcare All Payer |
$17,878.21
|
|
|
SPACER ELEOS TIBIAL POLY 10MM
|
Facility
|
IP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
