|
SOTALOL 1mg (150mg SDV)
|
Facility
|
IP
|
$17,963.20
|
|
|
Service Code
|
HCPCS C9482
|
| Hospital Charge Code |
25004195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,388.96 |
| Max. Negotiated Rate |
$17,244.67 |
| Rate for Payer: Aetna Commercial |
$13,831.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,011.30
|
| Rate for Payer: Cash Price |
$8,981.60
|
| Rate for Payer: Cigna Commercial |
$14,909.46
|
| Rate for Payer: First Health Commercial |
$17,065.04
|
| Rate for Payer: Humana Commercial |
$15,268.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,729.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,256.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,388.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,807.62
|
| Rate for Payer: Ohio Health Group HMO |
$13,472.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$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
|
|
|
SOTALOL 40MG/8ML ORAL LIQUID
|
Facility
|
IP
|
$32.70
|
|
|
Service Code
|
NDC 24338053025
|
| Hospital Charge Code |
25004391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.81 |
| Max. Negotiated Rate |
$31.39 |
| Rate for Payer: Aetna Commercial |
$25.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.51
|
| Rate for Payer: Cash Price |
$16.35
|
| Rate for Payer: Cigna Commercial |
$27.14
|
| Rate for Payer: First Health Commercial |
$31.07
|
| Rate for Payer: Humana Commercial |
$27.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.78
|
| Rate for Payer: Ohio Health Group HMO |
$24.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.56
|
| Rate for Payer: PHCS Commercial |
$31.39
|
| Rate for Payer: United Healthcare All Payer |
$28.78
|
|
|
SOTALOL 40MG/8ML ORAL LIQUID
|
Facility
|
OP
|
$32.70
|
|
|
Service Code
|
NDC 24338053025
|
| Hospital Charge Code |
25004391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.81 |
| Max. Negotiated Rate |
$31.39 |
| Rate for Payer: Aetna Commercial |
$25.18
|
| Rate for Payer: Anthem Medicaid |
$11.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.51
|
| Rate for Payer: Cash Price |
$16.35
|
| Rate for Payer: Cigna Commercial |
$27.14
|
| Rate for Payer: First Health Commercial |
$31.07
|
| Rate for Payer: Humana Commercial |
$27.80
|
| Rate for Payer: Humana KY Medicaid |
$11.25
|
| Rate for Payer: Kentucky WC Medicaid |
$11.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.78
|
| Rate for Payer: Ohio Health Group HMO |
$24.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.56
|
| Rate for Payer: PHCS Commercial |
$31.39
|
| Rate for Payer: United Healthcare All Payer |
$28.78
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
OP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem Medicaid |
$146.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Humana KY Medicaid |
$146.44
|
| Rate for Payer: Kentucky WC Medicaid |
$147.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.81
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
IP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.81
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Professional
|
Both
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$298.07 |
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$255.49
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$298.07
|
| Rate for Payer: UHCCP Medicaid |
$149.03
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
IP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.81
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
OP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004364
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem Medicaid |
$146.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Humana KY Medicaid |
$146.44
|
| Rate for Payer: Kentucky WC Medicaid |
$147.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.81
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
IP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004364
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.81
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 1% 2mL MDV
|
Facility
|
OP
|
$425.81
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$408.78 |
| Rate for Payer: Aetna Commercial |
$327.87
|
| Rate for Payer: Anthem Medicaid |
$146.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.13
|
| Rate for Payer: Cash Price |
$212.90
|
| Rate for Payer: Cigna Commercial |
$353.42
|
| Rate for Payer: First Health Commercial |
$404.52
|
| Rate for Payer: Humana Commercial |
$361.94
|
| Rate for Payer: Humana KY Medicaid |
$146.44
|
| Rate for Payer: Kentucky WC Medicaid |
$147.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.71
|
| Rate for Payer: Ohio Health Group HMO |
$319.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.81
|
| Rate for Payer: PHCS Commercial |
$408.78
|
| Rate for Payer: United Healthcare All Payer |
$374.71
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
OP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003478
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem Medicaid |
$144.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Humana KY Medicaid |
$144.32
|
| Rate for Payer: Kentucky WC Medicaid |
$145.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$335.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.56
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
OP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem Medicaid |
$144.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Humana KY Medicaid |
$144.32
|
| Rate for Payer: Kentucky WC Medicaid |
$145.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$335.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.56
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
IP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003478
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$335.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.56
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
IP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
636T0100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$335.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.56
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Professional
|
Both
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$293.75 |
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$251.79
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$293.75
|
| Rate for Payer: UHCCP Medicaid |
$146.88
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
IP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$335.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.56
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOTRADECOL 3%SOD TETRADCYL 2ML
|
Facility
|
OP
|
$419.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
63600100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$402.86 |
| Rate for Payer: Aetna Commercial |
$323.13
|
| Rate for Payer: Anthem Medicaid |
$144.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.33
|
| Rate for Payer: Cash Price |
$209.82
|
| Rate for Payer: Cigna Commercial |
$348.31
|
| Rate for Payer: First Health Commercial |
$398.67
|
| Rate for Payer: Humana Commercial |
$356.70
|
| Rate for Payer: Humana KY Medicaid |
$144.32
|
| Rate for Payer: Kentucky WC Medicaid |
$145.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.29
|
| Rate for Payer: Ohio Health Group HMO |
$314.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$335.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.56
|
| Rate for Payer: PHCS Commercial |
$402.86
|
| Rate for Payer: United Healthcare All Payer |
$369.29
|
|
|
SOYBEAN IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000873
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
SOYBEAN IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000873
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
SPACEOAR VUE SYSTEM
|
Facility
|
OP
|
$17,720.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$5,316.00 |
| Max. Negotiated Rate |
$17,011.20 |
| Rate for Payer: Aetna Commercial |
$13,644.40
|
| Rate for Payer: Anthem Medicaid |
$6,093.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,821.60
|
| Rate for Payer: Cash Price |
$8,860.00
|
| Rate for Payer: Cigna Commercial |
$14,707.60
|
| Rate for Payer: First Health Commercial |
$16,834.00
|
| Rate for Payer: Humana Commercial |
$15,062.00
|
| Rate for Payer: Humana KY Medicaid |
$6,093.91
|
| Rate for Payer: Kentucky WC Medicaid |
$6,155.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,530.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,077.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,316.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,216.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,593.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,290.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,416.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,226.80
|
| Rate for Payer: PHCS Commercial |
$17,011.20
|
| Rate for Payer: United Healthcare All Payer |
$15,593.60
|
|
|
SPACEOAR VUE SYSTEM
|
Facility
|
IP
|
$17,720.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$5,316.00 |
| Max. Negotiated Rate |
$17,011.20 |
| Rate for Payer: Aetna Commercial |
$13,644.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,821.60
|
| Rate for Payer: Cash Price |
$8,860.00
|
| Rate for Payer: Cigna Commercial |
$14,707.60
|
| Rate for Payer: First Health Commercial |
$16,834.00
|
| Rate for Payer: Humana Commercial |
$15,062.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,530.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,077.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,316.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,593.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,290.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,416.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,226.80
|
| Rate for Payer: PHCS Commercial |
$17,011.20
|
| Rate for Payer: United Healthcare All Payer |
$15,593.60
|
|
|
SPACER ELEOS TIBIAL POLY 10MM
|
Facility
|
OP
|
$13,431.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,029.31 |
| Max. Negotiated Rate |
$12,893.78 |
| Rate for Payer: Aetna Commercial |
$10,341.89
|
| Rate for Payer: Anthem Medicaid |
$4,618.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,476.20
|
| Rate for Payer: Cash Price |
$6,715.51
|
| Rate for Payer: Cigna Commercial |
$11,147.75
|
| Rate for Payer: First Health Commercial |
$12,759.47
|
| Rate for Payer: Humana Commercial |
$11,416.37
|
| Rate for Payer: Humana KY Medicaid |
$4,618.93
|
| Rate for Payer: Kentucky WC Medicaid |
$4,665.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,013.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,912.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,029.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,711.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,819.30
|
| Rate for Payer: Ohio Health Group HMO |
$10,073.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,744.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,684.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,267.40
|
| Rate for Payer: PHCS Commercial |
$12,893.78
|
| Rate for Payer: United Healthcare All Payer |
$11,819.30
|
|
|
SPACER ELEOS TIBIAL POLY 10MM
|
Facility
|
IP
|
$13,431.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,029.31 |
| Max. Negotiated Rate |
$12,893.78 |
| Rate for Payer: Aetna Commercial |
$10,341.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,476.20
|
| Rate for Payer: Cash Price |
$6,715.51
|
| Rate for Payer: Cigna Commercial |
$11,147.75
|
| Rate for Payer: First Health Commercial |
$12,759.47
|
| Rate for Payer: Humana Commercial |
$11,416.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,013.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,912.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,029.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,819.30
|
| Rate for Payer: Ohio Health Group HMO |
$10,073.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,744.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,684.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,267.40
|
| Rate for Payer: PHCS Commercial |
$12,893.78
|
| Rate for Payer: United Healthcare All Payer |
$11,819.30
|
|
|
SPACER ELEOS TIBIAL POLY 12MM
|
Facility
|
OP
|
$13,431.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,029.31 |
| Max. Negotiated Rate |
$12,893.78 |
| Rate for Payer: Aetna Commercial |
$10,341.89
|
| Rate for Payer: Anthem Medicaid |
$4,618.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,476.20
|
| Rate for Payer: Cash Price |
$6,715.51
|
| Rate for Payer: Cigna Commercial |
$11,147.75
|
| Rate for Payer: First Health Commercial |
$12,759.47
|
| Rate for Payer: Humana Commercial |
$11,416.37
|
| Rate for Payer: Humana KY Medicaid |
$4,618.93
|
| Rate for Payer: Kentucky WC Medicaid |
$4,665.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,013.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,912.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,029.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,711.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,819.30
|
| Rate for Payer: Ohio Health Group HMO |
$10,073.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,744.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,684.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,267.40
|
| Rate for Payer: PHCS Commercial |
$12,893.78
|
| Rate for Payer: United Healthcare All Payer |
$11,819.30
|
|
|
SPACER ELEOS TIBIAL POLY 12MM
|
Facility
|
IP
|
$13,431.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,029.31 |
| Max. Negotiated Rate |
$12,893.78 |
| Rate for Payer: Aetna Commercial |
$10,341.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,476.20
|
| Rate for Payer: Cash Price |
$6,715.51
|
| Rate for Payer: Cigna Commercial |
$11,147.75
|
| Rate for Payer: First Health Commercial |
$12,759.47
|
| Rate for Payer: Humana Commercial |
$11,416.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,013.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,912.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,029.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,819.30
|
| Rate for Payer: Ohio Health Group HMO |
$10,073.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,744.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,684.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,267.40
|
| Rate for Payer: PHCS Commercial |
$12,893.78
|
| Rate for Payer: United Healthcare All Payer |
$11,819.30
|
|
