|
SOLU MEDROL 5MG(500MG/4ML)
|
Facility
|
OP
|
$131.28
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
25002364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$126.03 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Anthem Medicaid |
$45.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cigna Commercial |
$108.96
|
| Rate for Payer: First Health Commercial |
$124.72
|
| Rate for Payer: Humana Commercial |
$111.59
|
| Rate for Payer: Humana KY Medicaid |
$45.15
|
| Rate for Payer: Humana Medicare Advantage |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$45.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.53
|
| Rate for Payer: Ohio Health Group HMO |
$98.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.58
|
| Rate for Payer: PHCS Commercial |
$126.03
|
| Rate for Payer: United Healthcare All Payer |
$115.53
|
|
|
SOLU MEDROL 5MG(500MG/4ML)
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
63600062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.02
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna Commercial |
$1.09
|
| Rate for Payer: First Health Commercial |
$1.24
|
| Rate for Payer: Humana Commercial |
$1.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.15
|
| Rate for Payer: Ohio Health Group HMO |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.90
|
| Rate for Payer: PHCS Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Payer |
$1.15
|
|
|
SOLU MEDROL 5MG(500MG/4ML)
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636T0062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.02
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna Commercial |
$1.09
|
| Rate for Payer: First Health Commercial |
$1.24
|
| Rate for Payer: Humana Commercial |
$1.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.15
|
| Rate for Payer: Ohio Health Group HMO |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.90
|
| Rate for Payer: PHCS Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Payer |
$1.15
|
|
|
SOLU MEDROL 5MG(500MG/4ML)
|
Facility
|
IP
|
$131.28
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
25002364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$126.03 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.40
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cigna Commercial |
$108.96
|
| Rate for Payer: First Health Commercial |
$124.72
|
| Rate for Payer: Humana Commercial |
$111.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.53
|
| Rate for Payer: Ohio Health Group HMO |
$98.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.58
|
| Rate for Payer: PHCS Commercial |
$126.03
|
| Rate for Payer: United Healthcare All Payer |
$115.53
|
|
|
SOLU MEDROL 5MG(500MG/4ML)
|
Professional
|
Both
|
$1.31
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
63600062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Ambetter Exchange |
$0.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.26
|
| Rate for Payer: Multiplan PHCS |
$0.79
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$0.34
|
| Rate for Payer: UHCCP Medicaid |
$0.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.26
|
|
|
SOLU MEDROL 5MG(500MG/4ML)
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
63600062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Anthem Medicaid |
$0.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna Commercial |
$1.09
|
| Rate for Payer: First Health Commercial |
$1.24
|
| Rate for Payer: Humana Commercial |
$1.11
|
| Rate for Payer: Humana KY Medicaid |
$0.45
|
| Rate for Payer: Humana Medicare Advantage |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$0.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.15
|
| Rate for Payer: Ohio Health Group HMO |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.90
|
| Rate for Payer: PHCS Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Payer |
$1.15
|
|
|
SOLU MEDROL 5MG(500MG/4ML)
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636T0062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Anthem Medicaid |
$0.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna Commercial |
$1.09
|
| Rate for Payer: First Health Commercial |
$1.24
|
| Rate for Payer: Humana Commercial |
$1.11
|
| Rate for Payer: Humana KY Medicaid |
$0.45
|
| Rate for Payer: Humana Medicare Advantage |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$0.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.15
|
| Rate for Payer: Ohio Health Group HMO |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.90
|
| Rate for Payer: PHCS Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Payer |
$1.15
|
|
|
SOLU-MEDROL 5MG (500mg SDV)
|
Facility
|
IP
|
$203.38
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
25003760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.01 |
| Max. Negotiated Rate |
$195.24 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.64
|
| Rate for Payer: Cash Price |
$101.69
|
| Rate for Payer: Cigna Commercial |
$168.81
|
| Rate for Payer: First Health Commercial |
$193.21
|
| Rate for Payer: Humana Commercial |
$172.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.97
|
| Rate for Payer: Ohio Health Group HMO |
$152.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.33
|
| Rate for Payer: PHCS Commercial |
$195.24
|
| Rate for Payer: United Healthcare All Payer |
$178.97
|
|
|
SOLU-MEDROL 5MG (500mg SDV)
|
Facility
|
OP
|
$203.38
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
25003760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$195.24 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Anthem Medicaid |
$69.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$101.69
|
| Rate for Payer: Cash Price |
$101.69
|
| Rate for Payer: Cigna Commercial |
$168.81
|
| Rate for Payer: First Health Commercial |
$193.21
|
| Rate for Payer: Humana Commercial |
$172.87
|
| Rate for Payer: Humana KY Medicaid |
$69.94
|
| Rate for Payer: Humana Medicare Advantage |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$70.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.97
|
| Rate for Payer: Ohio Health Group HMO |
$152.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.33
|
| Rate for Payer: PHCS Commercial |
$195.24
|
| Rate for Payer: United Healthcare All Payer |
$178.97
|
|
|
SOLYX BLUE
|
Facility
|
IP
|
$8,409.12
|
|
|
Service Code
|
HCPCS C1771
|
| Hospital Charge Code |
27000111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.74 |
| Max. Negotiated Rate |
$8,072.76 |
| Rate for Payer: Aetna Commercial |
$6,475.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,559.11
|
| Rate for Payer: Cash Price |
$4,204.56
|
| Rate for Payer: Cigna Commercial |
$6,979.57
|
| Rate for Payer: First Health Commercial |
$7,988.66
|
| Rate for Payer: Humana Commercial |
$7,147.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,895.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,205.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,522.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,400.03
|
| Rate for Payer: Ohio Health Group HMO |
$6,306.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,727.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,315.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,802.29
|
| Rate for Payer: PHCS Commercial |
$8,072.76
|
| Rate for Payer: United Healthcare All Payer |
$7,400.03
|
|
|
SOLYX BLUE
|
Facility
|
OP
|
$8,409.12
|
|
|
Service Code
|
HCPCS C1771
|
| Hospital Charge Code |
27000111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.74 |
| Max. Negotiated Rate |
$8,072.76 |
| Rate for Payer: Aetna Commercial |
$6,475.02
|
| Rate for Payer: Anthem Medicaid |
$2,891.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,559.11
|
| Rate for Payer: Cash Price |
$4,204.56
|
| Rate for Payer: Cigna Commercial |
$6,979.57
|
| Rate for Payer: First Health Commercial |
$7,988.66
|
| Rate for Payer: Humana Commercial |
$7,147.75
|
| Rate for Payer: Humana KY Medicaid |
$2,891.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,921.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,895.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,205.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,522.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,949.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,400.03
|
| Rate for Payer: Ohio Health Group HMO |
$6,306.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,727.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,315.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,802.29
|
| Rate for Payer: PHCS Commercial |
$8,072.76
|
| Rate for Payer: United Healthcare All Payer |
$7,400.03
|
|
|
SOMA 250MG TABLET
|
Facility
|
IP
|
$62.64
|
|
|
Service Code
|
NDC 51525590101
|
| Hospital Charge Code |
25001419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.79 |
| Max. Negotiated Rate |
$60.13 |
| Rate for Payer: Aetna Commercial |
$48.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.86
|
| Rate for Payer: Cash Price |
$31.32
|
| Rate for Payer: Cigna Commercial |
$51.99
|
| Rate for Payer: First Health Commercial |
$59.51
|
| Rate for Payer: Humana Commercial |
$53.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.12
|
| Rate for Payer: Ohio Health Group HMO |
$46.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.22
|
| Rate for Payer: PHCS Commercial |
$60.13
|
| Rate for Payer: United Healthcare All Payer |
$55.12
|
|
|
SOMA 250MG TABLET
|
Facility
|
OP
|
$62.64
|
|
|
Service Code
|
NDC 51525590101
|
| Hospital Charge Code |
25001419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.79 |
| Max. Negotiated Rate |
$60.13 |
| Rate for Payer: Aetna Commercial |
$48.23
|
| Rate for Payer: Anthem Medicaid |
$21.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.86
|
| Rate for Payer: Cash Price |
$31.32
|
| Rate for Payer: Cigna Commercial |
$51.99
|
| Rate for Payer: First Health Commercial |
$59.51
|
| Rate for Payer: Humana Commercial |
$53.24
|
| Rate for Payer: Humana KY Medicaid |
$21.54
|
| Rate for Payer: Kentucky WC Medicaid |
$21.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.12
|
| Rate for Payer: Ohio Health Group HMO |
$46.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.22
|
| Rate for Payer: PHCS Commercial |
$60.13
|
| Rate for Payer: United Healthcare All Payer |
$55.12
|
|
|
SOMA (CARISOPRODOL) 350MG/1TAB
|
Facility
|
OP
|
$60.07
|
|
|
Service Code
|
NDC 69584011110
|
| Hospital Charge Code |
25001418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$57.67 |
| Rate for Payer: Aetna Commercial |
$46.25
|
| Rate for Payer: Anthem Medicaid |
$20.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.85
|
| Rate for Payer: Cash Price |
$30.04
|
| Rate for Payer: Cigna Commercial |
$49.86
|
| Rate for Payer: First Health Commercial |
$57.07
|
| Rate for Payer: Humana Commercial |
$51.06
|
| Rate for Payer: Humana KY Medicaid |
$20.66
|
| Rate for Payer: Kentucky WC Medicaid |
$20.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.86
|
| Rate for Payer: Ohio Health Group HMO |
$45.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.45
|
| Rate for Payer: PHCS Commercial |
$57.67
|
| Rate for Payer: United Healthcare All Payer |
$52.86
|
|
|
SOMA (CARISOPRODOL) 350MG/1TAB
|
Facility
|
IP
|
$60.07
|
|
|
Service Code
|
NDC 69584011110
|
| Hospital Charge Code |
25001418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$57.67 |
| Rate for Payer: Aetna Commercial |
$46.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.85
|
| Rate for Payer: Cash Price |
$30.04
|
| Rate for Payer: Cigna Commercial |
$49.86
|
| Rate for Payer: First Health Commercial |
$57.07
|
| Rate for Payer: Humana Commercial |
$51.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.86
|
| Rate for Payer: Ohio Health Group HMO |
$45.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.45
|
| Rate for Payer: PHCS Commercial |
$57.67
|
| Rate for Payer: United Healthcare All Payer |
$52.86
|
|
|
SOMAGEN MESHED THIN 6*8
|
Facility
|
IP
|
$14,268.22
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,280.47 |
| Max. Negotiated Rate |
$13,697.49 |
| Rate for Payer: Aetna Commercial |
$10,986.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,129.21
|
| Rate for Payer: Cash Price |
$7,134.11
|
| Rate for Payer: Cigna Commercial |
$11,842.62
|
| Rate for Payer: First Health Commercial |
$13,554.81
|
| Rate for Payer: Humana Commercial |
$12,127.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,699.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,529.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,280.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,556.03
|
| Rate for Payer: Ohio Health Group HMO |
$10,701.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,414.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,413.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,845.07
|
| Rate for Payer: PHCS Commercial |
$13,697.49
|
| Rate for Payer: United Healthcare All Payer |
$12,556.03
|
|
|
SOMAGEN MESHED THIN 6*8
|
Facility
|
OP
|
$14,268.22
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,280.47 |
| Max. Negotiated Rate |
$13,697.49 |
| Rate for Payer: Aetna Commercial |
$10,986.53
|
| Rate for Payer: Anthem Medicaid |
$4,906.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,129.21
|
| Rate for Payer: Cash Price |
$7,134.11
|
| Rate for Payer: Cigna Commercial |
$11,842.62
|
| Rate for Payer: First Health Commercial |
$13,554.81
|
| Rate for Payer: Humana Commercial |
$12,127.99
|
| Rate for Payer: Humana KY Medicaid |
$4,906.84
|
| Rate for Payer: Kentucky WC Medicaid |
$4,956.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,699.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,529.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,280.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,005.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,556.03
|
| Rate for Payer: Ohio Health Group HMO |
$10,701.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,414.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,413.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,845.07
|
| Rate for Payer: PHCS Commercial |
$13,697.49
|
| Rate for Payer: United Healthcare All Payer |
$12,556.03
|
|
|
SOMAGEN MESHED THIN 8*12
|
Facility
|
IP
|
$25,649.82
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,694.95 |
| Max. Negotiated Rate |
$24,623.83 |
| Rate for Payer: Aetna Commercial |
$19,750.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,006.86
|
| Rate for Payer: Cash Price |
$12,824.91
|
| Rate for Payer: Cigna Commercial |
$21,289.35
|
| Rate for Payer: First Health Commercial |
$24,367.33
|
| Rate for Payer: Humana Commercial |
$21,802.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,032.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,929.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,694.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,571.84
|
| Rate for Payer: Ohio Health Group HMO |
$19,237.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,519.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,315.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,698.38
|
| Rate for Payer: PHCS Commercial |
$24,623.83
|
| Rate for Payer: United Healthcare All Payer |
$22,571.84
|
|
|
SOMAGEN MESHED THIN 8*12
|
Facility
|
OP
|
$25,649.82
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,694.95 |
| Max. Negotiated Rate |
$24,623.83 |
| Rate for Payer: Aetna Commercial |
$19,750.36
|
| Rate for Payer: Anthem Medicaid |
$8,820.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,006.86
|
| Rate for Payer: Cash Price |
$12,824.91
|
| Rate for Payer: Cigna Commercial |
$21,289.35
|
| Rate for Payer: First Health Commercial |
$24,367.33
|
| Rate for Payer: Humana Commercial |
$21,802.35
|
| Rate for Payer: Humana KY Medicaid |
$8,820.97
|
| Rate for Payer: Kentucky WC Medicaid |
$8,910.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,032.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,929.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,694.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,997.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,571.84
|
| Rate for Payer: Ohio Health Group HMO |
$19,237.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,519.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,315.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,698.38
|
| Rate for Payer: PHCS Commercial |
$24,623.83
|
| Rate for Payer: United Healthcare All Payer |
$22,571.84
|
|
|
SOMATOSENSORY TESTING
|
Facility
|
IP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
51000039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$400.50 |
| Max. Negotiated Rate |
$1,281.60 |
| Rate for Payer: Aetna Commercial |
$1,027.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,041.30
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$1,108.05
|
| Rate for Payer: First Health Commercial |
$1,268.25
|
| Rate for Payer: Humana Commercial |
$1,134.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$985.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$400.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,174.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$921.15
|
| Rate for Payer: PHCS Commercial |
$1,281.60
|
| Rate for Payer: United Healthcare All Payer |
$1,174.80
|
|
|
SOMATOSENSORY TESTING
|
Facility
|
OP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
51000039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$287.73 |
| Max. Negotiated Rate |
$1,281.60 |
| Rate for Payer: Aetna Commercial |
$1,027.95
|
| Rate for Payer: Anthem Medicaid |
$459.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,041.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$1,108.05
|
| Rate for Payer: First Health Commercial |
$1,268.25
|
| Rate for Payer: Humana Commercial |
$1,134.75
|
| Rate for Payer: Humana KY Medicaid |
$459.11
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$463.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$985.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$468.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,174.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$921.15
|
| Rate for Payer: PHCS Commercial |
$1,281.60
|
| Rate for Payer: United Healthcare All Payer |
$1,174.80
|
|
|
SOMATOSENSORY TESTING
|
Professional
|
Both
|
$1,335.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
51000039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.06 |
| Max. Negotiated Rate |
$801.00 |
| Rate for Payer: Aetna Commercial |
$176.38
|
| Rate for Payer: Ambetter Exchange |
$137.34
|
| Rate for Payer: Anthem Medicaid |
$59.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.81
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$127.74
|
| Rate for Payer: Healthspan PPO |
$155.35
|
| Rate for Payer: Humana Medicaid |
$59.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$32.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.45
|
| Rate for Payer: Molina Healthcare Passport |
$59.26
|
| Rate for Payer: Multiplan PHCS |
$801.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.54
|
| Rate for Payer: UHCCP Medicaid |
$467.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.34
|
|
|
SOMATOSENSORY TESTING(P
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
510P0039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.06 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$176.38
|
| Rate for Payer: Ambetter Exchange |
$137.34
|
| Rate for Payer: Anthem Medicaid |
$59.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.81
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$127.74
|
| Rate for Payer: Healthspan PPO |
$155.35
|
| Rate for Payer: Humana Medicaid |
$59.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$32.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.45
|
| Rate for Payer: Molina Healthcare Passport |
$59.26
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.54
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.34
|
|
|
SOMATOSENSORY TESTING(T
|
Facility
|
OP
|
$1,010.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
510T0039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$287.73 |
| Max. Negotiated Rate |
$969.60 |
| Rate for Payer: Aetna Commercial |
$777.70
|
| Rate for Payer: Anthem Medicaid |
$347.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$838.30
|
| Rate for Payer: First Health Commercial |
$959.50
|
| Rate for Payer: Humana Commercial |
$858.50
|
| Rate for Payer: Humana KY Medicaid |
$347.34
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$350.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$828.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$745.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$354.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$888.80
|
| Rate for Payer: Ohio Health Group HMO |
$757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$808.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$878.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$696.90
|
| Rate for Payer: PHCS Commercial |
$969.60
|
| Rate for Payer: United Healthcare All Payer |
$888.80
|
|
|
SOMATOSENSORY TESTING(T
|
Facility
|
IP
|
$1,010.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
510T0039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$303.00 |
| Max. Negotiated Rate |
$969.60 |
| Rate for Payer: Aetna Commercial |
$777.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.80
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$838.30
|
| Rate for Payer: First Health Commercial |
$959.50
|
| Rate for Payer: Humana Commercial |
$858.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$828.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$745.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$303.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$888.80
|
| Rate for Payer: Ohio Health Group HMO |
$757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$808.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$878.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$696.90
|
| Rate for Payer: PHCS Commercial |
$969.60
|
| Rate for Payer: United Healthcare All Payer |
$888.80
|
|
