|
SODIUM CHLORIDE 50 ML VIAL
|
Facility
|
IP
|
$79.21
|
|
|
Service Code
|
NDC 409488806
|
| Hospital Charge Code |
25003466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$76.04 |
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.78
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$65.74
|
| Rate for Payer: First Health Commercial |
$75.25
|
| Rate for Payer: Humana Commercial |
$67.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.70
|
| Rate for Payer: Ohio Health Group HMO |
$59.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.65
|
| Rate for Payer: PHCS Commercial |
$76.04
|
| Rate for Payer: United Healthcare All Payer |
$69.70
|
|
|
SODIUM CHLORIDE 50 ML VIAL
|
Facility
|
OP
|
$79.21
|
|
| Hospital Charge Code |
63600098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$76.04 |
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Anthem Medicaid |
$27.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.78
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$65.74
|
| Rate for Payer: First Health Commercial |
$75.25
|
| Rate for Payer: Humana Commercial |
$67.33
|
| Rate for Payer: Humana KY Medicaid |
$27.24
|
| Rate for Payer: Kentucky WC Medicaid |
$27.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.70
|
| Rate for Payer: Ohio Health Group HMO |
$59.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.65
|
| Rate for Payer: PHCS Commercial |
$76.04
|
| Rate for Payer: United Healthcare All Payer |
$69.70
|
|
|
SODIUM CHLORIDE 50 ML VIAL
|
Facility
|
IP
|
$79.21
|
|
| Hospital Charge Code |
636T0098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$76.04 |
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.78
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$65.74
|
| Rate for Payer: First Health Commercial |
$75.25
|
| Rate for Payer: Humana Commercial |
$67.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.70
|
| Rate for Payer: Ohio Health Group HMO |
$59.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.65
|
| Rate for Payer: PHCS Commercial |
$76.04
|
| Rate for Payer: United Healthcare All Payer |
$69.70
|
|
|
SODIUM CHLORIDE 50 ML VIAL
|
Facility
|
OP
|
$79.21
|
|
|
Service Code
|
NDC 409488806
|
| Hospital Charge Code |
25003466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$76.04 |
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Anthem Medicaid |
$27.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.78
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$65.74
|
| Rate for Payer: First Health Commercial |
$75.25
|
| Rate for Payer: Humana Commercial |
$67.33
|
| Rate for Payer: Humana KY Medicaid |
$27.24
|
| Rate for Payer: Kentucky WC Medicaid |
$27.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.70
|
| Rate for Payer: Ohio Health Group HMO |
$59.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.65
|
| Rate for Payer: PHCS Commercial |
$76.04
|
| Rate for Payer: United Healthcare All Payer |
$69.70
|
|
|
SODIUM CHLORIDE 50 ML VIAL
|
Facility
|
IP
|
$79.21
|
|
| Hospital Charge Code |
63600098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$76.04 |
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.78
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$65.74
|
| Rate for Payer: First Health Commercial |
$75.25
|
| Rate for Payer: Humana Commercial |
$67.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.70
|
| Rate for Payer: Ohio Health Group HMO |
$59.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.65
|
| Rate for Payer: PHCS Commercial |
$76.04
|
| Rate for Payer: United Healthcare All Payer |
$69.70
|
|
|
SODIUM CHLORIDE 50 ML VIAL
|
Professional
|
Both
|
$79.21
|
|
| Hospital Charge Code |
63600098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$55.45 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Multiplan PHCS |
$47.53
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.45
|
| Rate for Payer: UHCCP Medicaid |
$27.72
|
|
|
SODIUM CHLORIDE .9% (LVP) 25ML
|
Facility
|
IP
|
$67.43
|
|
|
Service Code
|
NDC 990798420
|
| Hospital Charge Code |
25003456
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$20.23 |
| Max. Negotiated Rate |
$64.73 |
| Rate for Payer: Aetna Commercial |
$51.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.60
|
| Rate for Payer: Cash Price |
$33.72
|
| Rate for Payer: Cigna Commercial |
$55.97
|
| Rate for Payer: First Health Commercial |
$64.06
|
| Rate for Payer: Humana Commercial |
$57.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.34
|
| Rate for Payer: Ohio Health Group HMO |
$50.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.53
|
| Rate for Payer: PHCS Commercial |
$64.73
|
| Rate for Payer: United Healthcare All Payer |
$59.34
|
|
|
SODIUM CHLORIDE .9% (LVP) 25ML
|
Facility
|
OP
|
$67.43
|
|
|
Service Code
|
NDC 990798420
|
| Hospital Charge Code |
25003456
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$20.23 |
| Max. Negotiated Rate |
$64.73 |
| Rate for Payer: Aetna Commercial |
$51.92
|
| Rate for Payer: Anthem Medicaid |
$23.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.60
|
| Rate for Payer: Cash Price |
$33.72
|
| Rate for Payer: Cigna Commercial |
$55.97
|
| Rate for Payer: First Health Commercial |
$64.06
|
| Rate for Payer: Humana Commercial |
$57.32
|
| Rate for Payer: Humana KY Medicaid |
$23.19
|
| Rate for Payer: Kentucky WC Medicaid |
$23.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.34
|
| Rate for Payer: Ohio Health Group HMO |
$50.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.53
|
| Rate for Payer: PHCS Commercial |
$64.73
|
| Rate for Payer: United Healthcare All Payer |
$59.34
|
|
|
SODIUM CHLORIDE IRRIG 250ML
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 990613822
|
| Hospital Charge Code |
25003470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
SODIUM CHLORIDE IRRIG 250ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990613822
|
| Hospital Charge Code |
25003470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| 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 |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| 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 |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
OP
|
$118.49
|
|
|
Service Code
|
NDC 990797208
|
| Hospital Charge Code |
25003469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.55 |
| Max. Negotiated Rate |
$113.75 |
| Rate for Payer: Aetna Commercial |
$91.24
|
| Rate for Payer: Anthem Medicaid |
$40.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.42
|
| Rate for Payer: Cash Price |
$59.24
|
| Rate for Payer: Cigna Commercial |
$98.35
|
| Rate for Payer: First Health Commercial |
$112.57
|
| Rate for Payer: Humana Commercial |
$100.72
|
| Rate for Payer: Humana KY Medicaid |
$40.75
|
| Rate for Payer: Kentucky WC Medicaid |
$41.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.27
|
| Rate for Payer: Ohio Health Group HMO |
$88.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.76
|
| Rate for Payer: PHCS Commercial |
$113.75
|
| Rate for Payer: United Healthcare All Payer |
$104.27
|
|
|
SODIUM CHLORIDE IRRIGAT 3000ML
|
Facility
|
IP
|
$118.49
|
|
|
Service Code
|
NDC 990797208
|
| Hospital Charge Code |
25003469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.55 |
| Max. Negotiated Rate |
$113.75 |
| Rate for Payer: Aetna Commercial |
$91.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.42
|
| Rate for Payer: Cash Price |
$59.24
|
| Rate for Payer: Cigna Commercial |
$98.35
|
| Rate for Payer: First Health Commercial |
$112.57
|
| Rate for Payer: Humana Commercial |
$100.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.27
|
| Rate for Payer: Ohio Health Group HMO |
$88.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.76
|
| Rate for Payer: PHCS Commercial |
$113.75
|
| Rate for Payer: United Healthcare All Payer |
$104.27
|
|
|
SODIUM CHLORIDE TABLE 1GM/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 69367022001
|
| Hospital Charge Code |
25001414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| 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 |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
SODIUM CHLORIDE TABLE 1GM/1TAB
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 69367022001
|
| Hospital Charge Code |
25001414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| 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 |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
SODIUM NITRITE 300MG/10ML
|
Facility
|
OP
|
$548.00
|
|
|
Service Code
|
NDC 60267031110
|
| Hospital Charge Code |
25003872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.40 |
| Max. Negotiated Rate |
$526.08 |
| Rate for Payer: Aetna Commercial |
$421.96
|
| Rate for Payer: Anthem Medicaid |
$188.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.44
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cigna Commercial |
$454.84
|
| Rate for Payer: First Health Commercial |
$520.60
|
| Rate for Payer: Humana Commercial |
$465.80
|
| Rate for Payer: Humana KY Medicaid |
$188.46
|
| Rate for Payer: Kentucky WC Medicaid |
$190.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.24
|
| Rate for Payer: Ohio Health Group HMO |
$411.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$438.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.12
|
| Rate for Payer: PHCS Commercial |
$526.08
|
| Rate for Payer: United Healthcare All Payer |
$482.24
|
|
|
SODIUM NITRITE 300MG/10ML
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
NDC 60267031110
|
| Hospital Charge Code |
25003872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.40 |
| Max. Negotiated Rate |
$526.08 |
| Rate for Payer: Aetna Commercial |
$421.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.44
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cigna Commercial |
$454.84
|
| Rate for Payer: First Health Commercial |
$520.60
|
| Rate for Payer: Humana Commercial |
$465.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.24
|
| Rate for Payer: Ohio Health Group HMO |
$411.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$438.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.12
|
| Rate for Payer: PHCS Commercial |
$526.08
|
| Rate for Payer: United Healthcare All Payer |
$482.24
|
|
|
SODIUM PHOSPHATE 45MMOL/15ML
|
Facility
|
OP
|
$197.21
|
|
|
Service Code
|
NDC 63323088116
|
| Hospital Charge Code |
25003472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.16 |
| 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 |
$157.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$171.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.07
|
| 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 |
$59.16 |
| 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 |
$157.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$171.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.07
|
| Rate for Payer: PHCS Commercial |
$189.32
|
| Rate for Payer: United Healthcare All Payer |
$173.54
|
|
|
SODIUM PHOSPHATES 15mMol SDV
|
Facility
|
IP
|
$87.96
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004426
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$26.39 |
| 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 |
$70.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.69
|
| Rate for Payer: PHCS Commercial |
$84.44
|
| Rate for Payer: United Healthcare All Payer |
$77.40
|
|
|
SODIUM PHOSPHATES 15mMol SDV
|
Facility
|
OP
|
$87.96
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004426
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$26.39 |
| 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 |
$70.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.69
|
| Rate for Payer: PHCS Commercial |
$84.44
|
| Rate for Payer: United Healthcare All Payer |
$77.40
|
|
|
SODIUM POLYSTYRENE S 15GM/60ML
|
Facility
|
IP
|
$41.80
|
|
|
Service Code
|
NDC 46287000660
|
| Hospital Charge Code |
25001417
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.54 |
| 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 |
$33.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.84
|
| Rate for Payer: PHCS Commercial |
$40.13
|
| Rate for Payer: United Healthcare All Payer |
$36.78
|
|
|
SODIUM POLYSTYRENE S 15GM/60ML
|
Facility
|
OP
|
$41.80
|
|
|
Service Code
|
NDC 46287000660
|
| Hospital Charge Code |
25001417
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.54 |
| 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 |
$33.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.84
|
| Rate for Payer: PHCS Commercial |
$40.13
|
| Rate for Payer: United Healthcare All Payer |
$36.78
|
|
|
SODIUM THIOSULFATE 25% VL(50ML
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002464
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$164.40 |
| Max. Negotiated Rate |
$526.08 |
| Rate for Payer: Aetna Commercial |
$421.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.44
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cigna Commercial |
$454.84
|
| Rate for Payer: First Health Commercial |
$520.60
|
| Rate for Payer: Humana Commercial |
$465.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.24
|
| Rate for Payer: Ohio Health Group HMO |
$411.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$438.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.12
|
| Rate for Payer: PHCS Commercial |
$526.08
|
| Rate for Payer: United Healthcare All Payer |
$482.24
|
|
