|
SODIUM ACETATE 40MEQ/20ML
|
Facility
|
IP
|
$118.19
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003447
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$35.46 |
| Max. Negotiated Rate |
$113.46 |
| Rate for Payer: Aetna Commercial |
$91.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.19
|
| Rate for Payer: Cash Price |
$59.09
|
| Rate for Payer: Cigna Commercial |
$98.10
|
| Rate for Payer: First Health Commercial |
$112.28
|
| Rate for Payer: Humana Commercial |
$100.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.01
|
| Rate for Payer: Ohio Health Group HMO |
$88.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.55
|
| Rate for Payer: PHCS Commercial |
$113.46
|
| Rate for Payer: United Healthcare All Payer |
$104.01
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Facility
|
IP
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003449
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Aetna Commercial |
$97.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.68
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cigna Commercial |
$105.00
|
| Rate for Payer: First Health Commercial |
$120.18
|
| Rate for Payer: Humana Commercial |
$107.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.33
|
| Rate for Payer: Ohio Health Group HMO |
$94.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.29
|
| Rate for Payer: PHCS Commercial |
$121.45
|
| Rate for Payer: United Healthcare All Payer |
$111.33
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Facility
|
OP
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003449
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Aetna Commercial |
$97.41
|
| Rate for Payer: Anthem Medicaid |
$43.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.68
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cigna Commercial |
$105.00
|
| Rate for Payer: First Health Commercial |
$120.18
|
| Rate for Payer: Humana Commercial |
$107.53
|
| Rate for Payer: Humana KY Medicaid |
$43.51
|
| Rate for Payer: Kentucky WC Medicaid |
$43.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.33
|
| Rate for Payer: Ohio Health Group HMO |
$94.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.29
|
| Rate for Payer: PHCS Commercial |
$121.45
|
| Rate for Payer: United Healthcare All Payer |
$111.33
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Facility
|
IP
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Aetna Commercial |
$97.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.68
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cigna Commercial |
$105.00
|
| Rate for Payer: First Health Commercial |
$120.18
|
| Rate for Payer: Humana Commercial |
$107.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.33
|
| Rate for Payer: Ohio Health Group HMO |
$94.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.29
|
| Rate for Payer: PHCS Commercial |
$121.45
|
| Rate for Payer: United Healthcare All Payer |
$111.33
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Professional
|
Both
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$88.56 |
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$75.91
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.56
|
| Rate for Payer: UHCCP Medicaid |
$44.28
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Facility
|
OP
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Aetna Commercial |
$97.41
|
| Rate for Payer: Anthem Medicaid |
$43.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.68
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cigna Commercial |
$105.00
|
| Rate for Payer: First Health Commercial |
$120.18
|
| Rate for Payer: Humana Commercial |
$107.53
|
| Rate for Payer: Humana KY Medicaid |
$43.51
|
| Rate for Payer: Kentucky WC Medicaid |
$43.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.33
|
| Rate for Payer: Ohio Health Group HMO |
$94.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.29
|
| Rate for Payer: PHCS Commercial |
$121.45
|
| Rate for Payer: United Healthcare All Payer |
$111.33
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Facility
|
OP
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Aetna Commercial |
$97.41
|
| Rate for Payer: Anthem Medicaid |
$43.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.68
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cigna Commercial |
$105.00
|
| Rate for Payer: First Health Commercial |
$120.18
|
| Rate for Payer: Humana Commercial |
$107.53
|
| Rate for Payer: Humana KY Medicaid |
$43.51
|
| Rate for Payer: Kentucky WC Medicaid |
$43.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.33
|
| Rate for Payer: Ohio Health Group HMO |
$94.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.29
|
| Rate for Payer: PHCS Commercial |
$121.45
|
| Rate for Payer: United Healthcare All Payer |
$111.33
|
|
|
SODIUM BICARBONATE 10MEQ/10ML
|
Facility
|
IP
|
$126.51
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$121.45 |
| Rate for Payer: Aetna Commercial |
$97.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.68
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cigna Commercial |
$105.00
|
| Rate for Payer: First Health Commercial |
$120.18
|
| Rate for Payer: Humana Commercial |
$107.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.33
|
| Rate for Payer: Ohio Health Group HMO |
$94.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.29
|
| Rate for Payer: PHCS Commercial |
$121.45
|
| Rate for Payer: United Healthcare All Payer |
$111.33
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
IP
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003450
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$121.62 |
| Rate for Payer: Aetna Commercial |
$97.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.82
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cigna Commercial |
$105.15
|
| Rate for Payer: First Health Commercial |
$120.36
|
| Rate for Payer: Humana Commercial |
$107.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.49
|
| Rate for Payer: Ohio Health Group HMO |
$95.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$121.62
|
| Rate for Payer: United Healthcare All Payer |
$111.49
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
OP
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003450
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$121.62 |
| Rate for Payer: Aetna Commercial |
$97.55
|
| Rate for Payer: Anthem Medicaid |
$43.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.82
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cigna Commercial |
$105.15
|
| Rate for Payer: First Health Commercial |
$120.36
|
| Rate for Payer: Humana Commercial |
$107.69
|
| Rate for Payer: Humana KY Medicaid |
$43.57
|
| Rate for Payer: Kentucky WC Medicaid |
$44.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.49
|
| Rate for Payer: Ohio Health Group HMO |
$95.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$121.62
|
| Rate for Payer: United Healthcare All Payer |
$111.49
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
OP
|
$116.74
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003451
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$35.02 |
| Max. Negotiated Rate |
$112.07 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Commercial |
$89.97
|
| Rate for Payer: Anthem Medicaid |
$40.15
|
| Rate for Payer: Anthem Medicaid |
$40.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.14
|
| Rate for Payer: Cash Price |
$58.37
|
| Rate for Payer: Cash Price |
$58.42
|
| Rate for Payer: Cigna Commercial |
$96.98
|
| Rate for Payer: Cigna Commercial |
$96.89
|
| Rate for Payer: First Health Commercial |
$111.00
|
| Rate for Payer: First Health Commercial |
$110.90
|
| Rate for Payer: Humana Commercial |
$99.23
|
| Rate for Payer: Humana Commercial |
$99.31
|
| Rate for Payer: Humana KY Medicaid |
$40.15
|
| Rate for Payer: Humana KY Medicaid |
$40.18
|
| Rate for Payer: Kentucky WC Medicaid |
$40.59
|
| Rate for Payer: Kentucky WC Medicaid |
$40.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.82
|
| Rate for Payer: Ohio Health Group HMO |
$87.56
|
| Rate for Payer: Ohio Health Group HMO |
$87.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.62
|
| Rate for Payer: PHCS Commercial |
$112.17
|
| Rate for Payer: PHCS Commercial |
$112.07
|
| Rate for Payer: United Healthcare All Payer |
$102.82
|
| Rate for Payer: United Healthcare All Payer |
$102.73
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
IP
|
$116.74
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003451
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$35.02 |
| Max. Negotiated Rate |
$112.07 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Commercial |
$89.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.14
|
| Rate for Payer: Cash Price |
$58.37
|
| Rate for Payer: Cash Price |
$58.42
|
| Rate for Payer: Cigna Commercial |
$96.89
|
| Rate for Payer: Cigna Commercial |
$96.98
|
| Rate for Payer: First Health Commercial |
$111.00
|
| Rate for Payer: First Health Commercial |
$110.90
|
| Rate for Payer: Humana Commercial |
$99.31
|
| Rate for Payer: Humana Commercial |
$99.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.82
|
| Rate for Payer: Ohio Health Group HMO |
$87.56
|
| Rate for Payer: Ohio Health Group HMO |
$87.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.55
|
| Rate for Payer: PHCS Commercial |
$112.07
|
| Rate for Payer: PHCS Commercial |
$112.17
|
| Rate for Payer: United Healthcare All Payer |
$102.73
|
| Rate for Payer: United Healthcare All Payer |
$102.82
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
IP
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$121.62 |
| Rate for Payer: Aetna Commercial |
$97.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.82
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cigna Commercial |
$105.15
|
| Rate for Payer: First Health Commercial |
$120.36
|
| Rate for Payer: Humana Commercial |
$107.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.49
|
| Rate for Payer: Ohio Health Group HMO |
$95.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$121.62
|
| Rate for Payer: United Healthcare All Payer |
$111.49
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
OP
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$121.62 |
| Rate for Payer: Aetna Commercial |
$97.55
|
| Rate for Payer: Anthem Medicaid |
$43.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.82
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cigna Commercial |
$105.15
|
| Rate for Payer: First Health Commercial |
$120.36
|
| Rate for Payer: Humana Commercial |
$107.69
|
| Rate for Payer: Humana KY Medicaid |
$43.57
|
| Rate for Payer: Kentucky WC Medicaid |
$44.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.49
|
| Rate for Payer: Ohio Health Group HMO |
$95.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$121.62
|
| Rate for Payer: United Healthcare All Payer |
$111.49
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
IP
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$121.62 |
| Rate for Payer: Aetna Commercial |
$97.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.82
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cigna Commercial |
$105.15
|
| Rate for Payer: First Health Commercial |
$120.36
|
| Rate for Payer: Humana Commercial |
$107.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.49
|
| Rate for Payer: Ohio Health Group HMO |
$95.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$121.62
|
| Rate for Payer: United Healthcare All Payer |
$111.49
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Professional
|
Both
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$88.68 |
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$76.01
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.68
|
| Rate for Payer: UHCCP Medicaid |
$44.34
|
|
|
SODIUM BICARBONATE 50MEQ/50ML
|
Facility
|
OP
|
$126.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$121.62 |
| Rate for Payer: Aetna Commercial |
$97.55
|
| Rate for Payer: Anthem Medicaid |
$43.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.82
|
| Rate for Payer: Cash Price |
$63.34
|
| Rate for Payer: Cigna Commercial |
$105.15
|
| Rate for Payer: First Health Commercial |
$120.36
|
| Rate for Payer: Humana Commercial |
$107.69
|
| Rate for Payer: Humana KY Medicaid |
$43.57
|
| Rate for Payer: Kentucky WC Medicaid |
$44.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.49
|
| Rate for Payer: Ohio Health Group HMO |
$95.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$121.62
|
| Rate for Payer: United Healthcare All Payer |
$111.49
|
|
|
SODIUM BICARBONATE 650MG/1TAB
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001412
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
SODIUM BICARBONATE 650MG/1TAB
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001412
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
SODIUM BLOOD
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
HCPCS 84295
|
| Hospital Charge Code |
30000511
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.40 |
| Max. Negotiated Rate |
$55.68 |
| Rate for Payer: Aetna Commercial |
$44.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.57
|
| Rate for Payer: Cash Price |
$29.00
|
| Rate for Payer: Cigna Commercial |
$48.14
|
| Rate for Payer: First Health Commercial |
$55.10
|
| Rate for Payer: Humana Commercial |
$49.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$47.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$51.04
|
| Rate for Payer: Ohio Health Group HMO |
$43.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.02
|
| Rate for Payer: PHCS Commercial |
$55.68
|
| Rate for Payer: United Healthcare All Payer |
$51.04
|
|
|
SODIUM BLOOD
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
HCPCS 84295
|
| Hospital Charge Code |
30000511
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$55.68 |
| Rate for Payer: Aetna Commercial |
$44.66
|
| Rate for Payer: Anthem Medicaid |
$4.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$29.00
|
| Rate for Payer: Cash Price |
$29.00
|
| Rate for Payer: Cigna Commercial |
$48.14
|
| Rate for Payer: First Health Commercial |
$55.10
|
| Rate for Payer: Humana Commercial |
$49.30
|
| Rate for Payer: Humana KY Medicaid |
$4.81
|
| Rate for Payer: Humana Medicare Advantage |
$4.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$47.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$51.04
|
| Rate for Payer: Ohio Health Group HMO |
$43.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.02
|
| Rate for Payer: PHCS Commercial |
$55.68
|
| Rate for Payer: United Healthcare All Payer |
$51.04
|
|
|
SODIUM CHLOR 7% NEBULIZ V NEB
|
Facility
|
OP
|
$4.48
|
|
|
Service Code
|
NDC 83490030760
|
| Hospital Charge Code |
25003453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.30 |
| Rate for Payer: Aetna Commercial |
$3.45
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.72
|
| Rate for Payer: First Health Commercial |
$4.26
|
| Rate for Payer: Humana Commercial |
$3.81
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.09
|
| Rate for Payer: PHCS Commercial |
$4.30
|
| Rate for Payer: United Healthcare All Payer |
$3.94
|
|
|
SODIUM CHLOR 7% NEBULIZ V NEB
|
Facility
|
IP
|
$4.48
|
|
|
Service Code
|
NDC 83490030760
|
| Hospital Charge Code |
25003453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.30 |
| Rate for Payer: Aetna Commercial |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.72
|
| Rate for Payer: First Health Commercial |
$4.26
|
| Rate for Payer: Humana Commercial |
$3.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.94
|
| Rate for Payer: Ohio Health Group HMO |
$3.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.09
|
| Rate for Payer: PHCS Commercial |
$4.30
|
| Rate for Payer: United Healthcare All Payer |
$3.94
|
|
|
SODIUM CHLOR/ALOE VERA 0.5OZ
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 225052547
|
| Hospital Charge Code |
25001415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.16
|
| Rate for Payer: Anthem Medicaid |
$0.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.17
|
| Rate for Payer: First Health Commercial |
$0.20
|
| Rate for Payer: Humana Commercial |
$0.18
|
| Rate for Payer: Humana KY Medicaid |
$0.07
|
| Rate for Payer: Kentucky WC Medicaid |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.18
|
| Rate for Payer: Ohio Health Group HMO |
$0.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.14
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
SODIUM CHLOR/ALOE VERA 0.5OZ
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 225052547
|
| Hospital Charge Code |
25001415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.17
|
| Rate for Payer: First Health Commercial |
$0.20
|
| Rate for Payer: Humana Commercial |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.18
|
| Rate for Payer: Ohio Health Group HMO |
$0.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.14
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
