|
SOMATROPIN 1mg (6mg SDV)
|
Facility
|
IP
|
$1,872.60
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$561.78 |
| Max. Negotiated Rate |
$1,797.70 |
| Rate for Payer: Aetna Commercial |
$1,441.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,460.63
|
| Rate for Payer: Cash Price |
$936.30
|
| Rate for Payer: Cigna Commercial |
$1,554.26
|
| Rate for Payer: First Health Commercial |
$1,778.97
|
| Rate for Payer: Humana Commercial |
$1,591.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,535.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,647.89
|
| Rate for Payer: Ohio Health Group HMO |
$1,404.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,498.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,629.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,292.09
|
| Rate for Payer: PHCS Commercial |
$1,797.70
|
| Rate for Payer: United Healthcare All Payer |
$1,647.89
|
|
|
SOMATROPIN 1mg (6mg SDV)
|
Facility
|
OP
|
$1,872.60
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$1,797.70 |
| Rate for Payer: Aetna Commercial |
$1,441.90
|
| Rate for Payer: Anthem Medicaid |
$643.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,460.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$68.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.04
|
| Rate for Payer: Cash Price |
$936.30
|
| Rate for Payer: Cash Price |
$936.30
|
| Rate for Payer: Cigna Commercial |
$1,554.26
|
| Rate for Payer: First Health Commercial |
$1,778.97
|
| Rate for Payer: Humana Commercial |
$1,591.71
|
| Rate for Payer: Humana KY Medicaid |
$643.99
|
| Rate for Payer: Humana Medicare Advantage |
$48.92
|
| Rate for Payer: Kentucky WC Medicaid |
$650.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,535.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,647.89
|
| Rate for Payer: Ohio Health Group HMO |
$1,404.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,498.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,629.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,292.09
|
| Rate for Payer: PHCS Commercial |
$1,797.70
|
| Rate for Payer: United Healthcare All Payer |
$1,647.89
|
|
|
SOMATULINE DEPOT 1mg(120mg)PFS
|
Facility
|
IP
|
$52,112.90
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15,633.87 |
| Max. Negotiated Rate |
$50,028.38 |
| Rate for Payer: Aetna Commercial |
$40,126.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40,648.06
|
| Rate for Payer: Cash Price |
$26,056.45
|
| Rate for Payer: Cigna Commercial |
$43,253.71
|
| Rate for Payer: First Health Commercial |
$49,507.25
|
| Rate for Payer: Humana Commercial |
$44,295.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42,732.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38,459.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,633.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$45,859.35
|
| Rate for Payer: Ohio Health Group HMO |
$39,084.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41,690.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45,338.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35,957.90
|
| Rate for Payer: PHCS Commercial |
$50,028.38
|
| Rate for Payer: United Healthcare All Payer |
$45,859.35
|
|
|
SOMATULINE DEPOT 1mg(120mg)PFS
|
Facility
|
OP
|
$52,112.90
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$50,028.38 |
| Rate for Payer: Aetna Commercial |
$40,126.93
|
| Rate for Payer: Anthem Medicaid |
$17,921.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40,648.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$51.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.49
|
| Rate for Payer: Cash Price |
$26,056.45
|
| Rate for Payer: Cash Price |
$26,056.45
|
| Rate for Payer: Cigna Commercial |
$43,253.71
|
| Rate for Payer: First Health Commercial |
$49,507.25
|
| Rate for Payer: Humana Commercial |
$44,295.96
|
| Rate for Payer: Humana KY Medicaid |
$17,921.63
|
| Rate for Payer: Humana Medicare Advantage |
$36.66
|
| Rate for Payer: Kentucky WC Medicaid |
$18,104.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42,732.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38,459.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,281.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$45,859.35
|
| Rate for Payer: Ohio Health Group HMO |
$39,084.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41,690.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45,338.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35,957.90
|
| Rate for Payer: PHCS Commercial |
$50,028.38
|
| Rate for Payer: United Healthcare All Payer |
$45,859.35
|
|
|
SOMATULINE DEPOT 1mg (60mg)PFS
|
Facility
|
IP
|
$33,179.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,953.88 |
| Max. Negotiated Rate |
$31,852.42 |
| Rate for Payer: Aetna Commercial |
$25,548.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,880.09
|
| Rate for Payer: Cash Price |
$16,589.80
|
| Rate for Payer: Cigna Commercial |
$27,539.07
|
| Rate for Payer: First Health Commercial |
$31,520.62
|
| Rate for Payer: Humana Commercial |
$28,202.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,207.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,486.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,953.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,198.05
|
| Rate for Payer: Ohio Health Group HMO |
$24,884.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,543.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,866.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,893.92
|
| Rate for Payer: PHCS Commercial |
$31,852.42
|
| Rate for Payer: United Healthcare All Payer |
$29,198.05
|
|
|
SOMATULINE DEPOT 1mg (60mg)PFS
|
Facility
|
OP
|
$33,179.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$31,852.42 |
| Rate for Payer: Aetna Commercial |
$25,548.29
|
| Rate for Payer: Anthem Medicaid |
$11,410.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,880.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$51.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.49
|
| Rate for Payer: Cash Price |
$16,589.80
|
| Rate for Payer: Cash Price |
$16,589.80
|
| Rate for Payer: Cigna Commercial |
$27,539.07
|
| Rate for Payer: First Health Commercial |
$31,520.62
|
| Rate for Payer: Humana Commercial |
$28,202.66
|
| Rate for Payer: Humana KY Medicaid |
$11,410.46
|
| Rate for Payer: Humana Medicare Advantage |
$36.66
|
| Rate for Payer: Kentucky WC Medicaid |
$11,526.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,207.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,486.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,639.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,198.05
|
| Rate for Payer: Ohio Health Group HMO |
$24,884.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,543.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,866.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,893.92
|
| Rate for Payer: PHCS Commercial |
$31,852.42
|
| Rate for Payer: United Healthcare All Payer |
$29,198.05
|
|
|
SOMATULINE DEPOT 1mg (90mg)PFS
|
Facility
|
OP
|
$44,188.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$42,421.06 |
| Rate for Payer: Aetna Commercial |
$34,025.22
|
| Rate for Payer: Anthem Medicaid |
$15,196.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,467.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$51.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.49
|
| Rate for Payer: Cash Price |
$22,094.30
|
| Rate for Payer: Cash Price |
$22,094.30
|
| Rate for Payer: Cigna Commercial |
$36,676.54
|
| Rate for Payer: First Health Commercial |
$41,979.17
|
| Rate for Payer: Humana Commercial |
$37,560.31
|
| Rate for Payer: Humana KY Medicaid |
$15,196.46
|
| Rate for Payer: Humana Medicare Advantage |
$36.66
|
| Rate for Payer: Kentucky WC Medicaid |
$15,351.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,234.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,611.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,501.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,885.97
|
| Rate for Payer: Ohio Health Group HMO |
$33,141.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35,350.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38,444.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30,490.13
|
| Rate for Payer: PHCS Commercial |
$42,421.06
|
| Rate for Payer: United Healthcare All Payer |
$38,885.97
|
|
|
SOMATULINE DEPOT 1mg (90mg)PFS
|
Facility
|
IP
|
$44,188.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,256.58 |
| Max. Negotiated Rate |
$42,421.06 |
| Rate for Payer: Aetna Commercial |
$34,025.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,467.11
|
| Rate for Payer: Cash Price |
$22,094.30
|
| Rate for Payer: Cigna Commercial |
$36,676.54
|
| Rate for Payer: First Health Commercial |
$41,979.17
|
| Rate for Payer: Humana Commercial |
$37,560.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,234.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,611.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,256.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,885.97
|
| Rate for Payer: Ohio Health Group HMO |
$33,141.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35,350.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38,444.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30,490.13
|
| Rate for Payer: PHCS Commercial |
$42,421.06
|
| Rate for Payer: United Healthcare All Payer |
$38,885.97
|
|
|
SON 2 CATH 5F
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SON 2 CATH 5F
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SONICANCHOR 2.5X10 FIBER 0
|
Facility
|
IP
|
$3,959.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.78 |
| Max. Negotiated Rate |
$3,800.89 |
| Rate for Payer: Aetna Commercial |
$3,048.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.22
|
| Rate for Payer: Cash Price |
$1,979.63
|
| Rate for Payer: Cigna Commercial |
$3,286.19
|
| Rate for Payer: First Health Commercial |
$3,761.30
|
| Rate for Payer: Humana Commercial |
$3,365.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,921.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,167.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,444.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,731.89
|
| Rate for Payer: PHCS Commercial |
$3,800.89
|
| Rate for Payer: United Healthcare All Payer |
$3,484.15
|
|
|
SONICANCHOR 2.5X10 FIBER 0
|
Facility
|
OP
|
$3,959.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.78 |
| Max. Negotiated Rate |
$3,800.89 |
| Rate for Payer: Aetna Commercial |
$3,048.63
|
| Rate for Payer: Anthem Medicaid |
$1,361.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.22
|
| Rate for Payer: Cash Price |
$1,979.63
|
| Rate for Payer: Cigna Commercial |
$3,286.19
|
| Rate for Payer: First Health Commercial |
$3,761.30
|
| Rate for Payer: Humana Commercial |
$3,365.37
|
| Rate for Payer: Humana KY Medicaid |
$1,361.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,375.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,921.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,388.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,167.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,444.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,731.89
|
| Rate for Payer: PHCS Commercial |
$3,800.89
|
| Rate for Payer: United Healthcare All Payer |
$3,484.15
|
|
|
SONICANCHOR 2.5X10 FIBER 2
|
Facility
|
IP
|
$3,959.26
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.78 |
| Max. Negotiated Rate |
$3,800.89 |
| Rate for Payer: Aetna Commercial |
$3,048.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.22
|
| Rate for Payer: Cash Price |
$1,979.63
|
| Rate for Payer: Cigna Commercial |
$3,286.19
|
| Rate for Payer: First Health Commercial |
$3,761.30
|
| Rate for Payer: Humana Commercial |
$3,365.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,921.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,167.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,444.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,731.89
|
| Rate for Payer: PHCS Commercial |
$3,800.89
|
| Rate for Payer: United Healthcare All Payer |
$3,484.15
|
|
|
SONICANCHOR 2.5X10 FIBER 2
|
Facility
|
OP
|
$3,959.26
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.78 |
| Max. Negotiated Rate |
$3,800.89 |
| Rate for Payer: Aetna Commercial |
$3,048.63
|
| Rate for Payer: Anthem Medicaid |
$1,361.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.22
|
| Rate for Payer: Cash Price |
$1,979.63
|
| Rate for Payer: Cigna Commercial |
$3,286.19
|
| Rate for Payer: First Health Commercial |
$3,761.30
|
| Rate for Payer: Humana Commercial |
$3,365.37
|
| Rate for Payer: Humana KY Medicaid |
$1,361.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,375.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,921.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,388.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,167.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,444.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,731.89
|
| Rate for Payer: PHCS Commercial |
$3,800.89
|
| Rate for Payer: United Healthcare All Payer |
$3,484.15
|
|
|
SONICANCHOR 2.5X10 FIBER 2-0
|
Facility
|
IP
|
$3,959.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.78 |
| Max. Negotiated Rate |
$3,800.89 |
| Rate for Payer: Aetna Commercial |
$3,048.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.22
|
| Rate for Payer: Cash Price |
$1,979.63
|
| Rate for Payer: Cigna Commercial |
$3,286.19
|
| Rate for Payer: First Health Commercial |
$3,761.30
|
| Rate for Payer: Humana Commercial |
$3,365.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,921.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,167.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,444.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,731.89
|
| Rate for Payer: PHCS Commercial |
$3,800.89
|
| Rate for Payer: United Healthcare All Payer |
$3,484.15
|
|
|
SONICANCHOR 2.5X10 FIBER 2-0
|
Facility
|
OP
|
$3,959.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.78 |
| Max. Negotiated Rate |
$3,800.89 |
| Rate for Payer: Aetna Commercial |
$3,048.63
|
| Rate for Payer: Anthem Medicaid |
$1,361.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,088.22
|
| Rate for Payer: Cash Price |
$1,979.63
|
| Rate for Payer: Cigna Commercial |
$3,286.19
|
| Rate for Payer: First Health Commercial |
$3,761.30
|
| Rate for Payer: Humana Commercial |
$3,365.37
|
| Rate for Payer: Humana KY Medicaid |
$1,361.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,375.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,246.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,921.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,187.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,388.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,484.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,969.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,167.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,444.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,731.89
|
| Rate for Payer: PHCS Commercial |
$3,800.89
|
| Rate for Payer: United Healthcare All Payer |
$3,484.15
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR
|
Facility
|
IP
|
$1,071.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$321.30 |
| Max. Negotiated Rate |
$1,028.16 |
| Rate for Payer: Aetna Commercial |
$824.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$835.38
|
| Rate for Payer: Cash Price |
$535.50
|
| Rate for Payer: Cigna Commercial |
$888.93
|
| Rate for Payer: First Health Commercial |
$1,017.45
|
| Rate for Payer: Humana Commercial |
$910.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$878.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$790.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$321.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$942.48
|
| Rate for Payer: Ohio Health Group HMO |
$803.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$856.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$931.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$738.99
|
| Rate for Payer: PHCS Commercial |
$1,028.16
|
| Rate for Payer: United Healthcare All Payer |
$942.48
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR
|
Facility
|
OP
|
$1,071.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$1,028.16 |
| Rate for Payer: Aetna Commercial |
$824.67
|
| Rate for Payer: Anthem Medicaid |
$368.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$835.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$535.50
|
| Rate for Payer: Cash Price |
$535.50
|
| Rate for Payer: Cigna Commercial |
$888.93
|
| Rate for Payer: First Health Commercial |
$1,017.45
|
| Rate for Payer: Humana Commercial |
$910.35
|
| Rate for Payer: Humana KY Medicaid |
$368.32
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$372.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$878.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$790.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$375.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$942.48
|
| Rate for Payer: Ohio Health Group HMO |
$803.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$856.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$931.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$738.99
|
| Rate for Payer: PHCS Commercial |
$1,028.16
|
| Rate for Payer: United Healthcare All Payer |
$942.48
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR
|
Professional
|
Both
|
$1,071.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$45.31 |
| Max. Negotiated Rate |
$642.60 |
| Rate for Payer: Aetna Commercial |
$182.48
|
| Rate for Payer: Ambetter Exchange |
$103.01
|
| Rate for Payer: Anthem Medicaid |
$70.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$103.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$103.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$123.61
|
| Rate for Payer: Cash Price |
$535.50
|
| Rate for Payer: Cash Price |
$535.50
|
| Rate for Payer: Cigna Commercial |
$156.50
|
| Rate for Payer: Healthspan PPO |
$170.99
|
| Rate for Payer: Humana Medicaid |
$70.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$103.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.50
|
| Rate for Payer: Molina Healthcare Passport |
$70.10
|
| Rate for Payer: Multiplan PHCS |
$642.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$133.91
|
| Rate for Payer: UHCCP Medicaid |
$374.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.01
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
402P0045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$45.31 |
| Max. Negotiated Rate |
$182.48 |
| Rate for Payer: Aetna Commercial |
$182.48
|
| Rate for Payer: Ambetter Exchange |
$103.01
|
| Rate for Payer: Anthem Medicaid |
$70.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$103.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$103.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$123.61
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$156.50
|
| Rate for Payer: Healthspan PPO |
$170.99
|
| Rate for Payer: Humana Medicaid |
$70.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$103.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.50
|
| Rate for Payer: Molina Healthcare Passport |
$70.10
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$133.91
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.01
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR(T
|
Facility
|
IP
|
$836.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
402T0045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$250.80 |
| Max. Negotiated Rate |
$802.56 |
| Rate for Payer: Aetna Commercial |
$643.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.08
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$693.88
|
| Rate for Payer: First Health Commercial |
$794.20
|
| Rate for Payer: Humana Commercial |
$710.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$685.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$735.68
|
| Rate for Payer: Ohio Health Group HMO |
$627.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.84
|
| Rate for Payer: PHCS Commercial |
$802.56
|
| Rate for Payer: United Healthcare All Payer |
$735.68
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR(T
|
Facility
|
OP
|
$836.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
402T0045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$802.56 |
| Rate for Payer: Aetna Commercial |
$643.72
|
| Rate for Payer: Anthem Medicaid |
$287.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$693.88
|
| Rate for Payer: First Health Commercial |
$794.20
|
| Rate for Payer: Humana Commercial |
$710.60
|
| Rate for Payer: Humana KY Medicaid |
$287.50
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$290.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$685.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$293.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$735.68
|
| Rate for Payer: Ohio Health Group HMO |
$627.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.84
|
| Rate for Payer: PHCS Commercial |
$802.56
|
| Rate for Payer: United Healthcare All Payer |
$735.68
|
|
|
SORBITOL 70% SOLUTION 30ML
|
Facility
|
OP
|
$10.89
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
25003477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Aetna Commercial |
$8.39
|
| Rate for Payer: Anthem Medicaid |
$3.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.04
|
| Rate for Payer: First Health Commercial |
$10.35
|
| Rate for Payer: Humana Commercial |
$9.26
|
| Rate for Payer: Humana KY Medicaid |
$3.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.58
|
| Rate for Payer: Ohio Health Group HMO |
$8.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.51
|
| Rate for Payer: PHCS Commercial |
$10.45
|
| Rate for Payer: United Healthcare All Payer |
$9.58
|
|
|
SORBITOL 70% SOLUTION 30ML
|
Facility
|
IP
|
$10.89
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
25003477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Aetna Commercial |
$8.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cigna Commercial |
$9.04
|
| Rate for Payer: First Health Commercial |
$10.35
|
| Rate for Payer: Humana Commercial |
$9.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.58
|
| Rate for Payer: Ohio Health Group HMO |
$8.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.51
|
| Rate for Payer: PHCS Commercial |
$10.45
|
| Rate for Payer: United Healthcare All Payer |
$9.58
|
|
|
SOTALOL 1mg (150mg SDV)
|
Facility
|
OP
|
$17,963.20
|
|
|
Service Code
|
HCPCS C9482
|
| Hospital Charge Code |
25004195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$17,244.67 |
| Rate for Payer: Aetna Commercial |
$13,831.66
|
| Rate for Payer: Anthem Medicaid |
$6,177.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,011.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.82
|
| Rate for Payer: Cash Price |
$8,981.60
|
| Rate for Payer: Cash Price |
$8,981.60
|
| Rate for Payer: Cigna Commercial |
$14,909.46
|
| Rate for Payer: First Health Commercial |
$17,065.04
|
| Rate for Payer: Humana Commercial |
$15,268.72
|
| Rate for Payer: Humana KY Medicaid |
$6,177.54
|
| Rate for Payer: Humana Medicare Advantage |
$25.05
|
| Rate for Payer: Kentucky WC Medicaid |
$6,240.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,729.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,256.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,301.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,807.62
|
| Rate for Payer: Ohio Health Group HMO |
$13,472.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,627.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,394.61
|
| Rate for Payer: PHCS Commercial |
$17,244.67
|
| Rate for Payer: United Healthcare All Payer |
$15,807.62
|
|
