|
BREEZA
|
Facility
|
OP
|
$11.81
|
|
|
Service Code
|
NDC 15137002126
|
| Hospital Charge Code |
25004547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$11.34 |
| Rate for Payer: Aetna Commercial |
$9.09
|
| Rate for Payer: Anthem Medicaid |
$4.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.21
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cigna Commercial |
$9.80
|
| Rate for Payer: First Health Commercial |
$11.22
|
| Rate for Payer: Humana Commercial |
$10.04
|
| Rate for Payer: Humana KY Medicaid |
$4.06
|
| Rate for Payer: Kentucky WC Medicaid |
$4.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.39
|
| Rate for Payer: Ohio Health Group HMO |
$8.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.15
|
| Rate for Payer: PHCS Commercial |
$11.34
|
| Rate for Payer: United Healthcare All Payer |
$10.39
|
|
|
BRETHINE(TERBUTALIN 2.5MG/1TAB
|
Facility
|
IP
|
$12.35
|
|
|
Service Code
|
NDC 527131801
|
| Hospital Charge Code |
25000345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna Commercial |
$9.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.63
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna Commercial |
$10.25
|
| Rate for Payer: First Health Commercial |
$11.73
|
| Rate for Payer: Humana Commercial |
$10.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.87
|
| Rate for Payer: Ohio Health Group HMO |
$9.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.52
|
| Rate for Payer: PHCS Commercial |
$11.86
|
| Rate for Payer: United Healthcare All Payer |
$10.87
|
|
|
BRETHINE(TERBUTALIN 2.5MG/1TAB
|
Facility
|
OP
|
$12.35
|
|
|
Service Code
|
NDC 527131801
|
| Hospital Charge Code |
25000345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna Commercial |
$9.51
|
| Rate for Payer: Anthem Medicaid |
$4.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.63
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna Commercial |
$10.25
|
| Rate for Payer: First Health Commercial |
$11.73
|
| Rate for Payer: Humana Commercial |
$10.50
|
| Rate for Payer: Humana KY Medicaid |
$4.25
|
| Rate for Payer: Kentucky WC Medicaid |
$4.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.87
|
| Rate for Payer: Ohio Health Group HMO |
$9.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.52
|
| Rate for Payer: PHCS Commercial |
$11.86
|
| Rate for Payer: United Healthcare All Payer |
$10.87
|
|
|
BRETHINE(TERBUTALINE) 1MG/1ML
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
25002383
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$61.60
|
| Rate for Payer: Anthem Medicaid |
$27.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.40
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$66.40
|
| Rate for Payer: First Health Commercial |
$76.00
|
| Rate for Payer: Humana Commercial |
$68.00
|
| Rate for Payer: Humana KY Medicaid |
$27.51
|
| Rate for Payer: Kentucky WC Medicaid |
$27.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.40
|
| Rate for Payer: Ohio Health Group HMO |
$60.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.20
|
| Rate for Payer: PHCS Commercial |
$76.80
|
| Rate for Payer: United Healthcare All Payer |
$70.40
|
|
|
BRETHINE(TERBUTALINE) 1MG/1ML
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
25002383
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$61.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.40
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$66.40
|
| Rate for Payer: First Health Commercial |
$76.00
|
| Rate for Payer: Humana Commercial |
$68.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.40
|
| Rate for Payer: Ohio Health Group HMO |
$60.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.20
|
| Rate for Payer: PHCS Commercial |
$76.80
|
| Rate for Payer: United Healthcare All Payer |
$70.40
|
|
|
BREVITAL (METHO 500MG/50ML
|
Facility
|
OP
|
$186.53
|
|
|
Service Code
|
NDC 42023010501
|
| Hospital Charge Code |
25003855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.96 |
| Max. Negotiated Rate |
$179.07 |
| Rate for Payer: Aetna Commercial |
$143.63
|
| Rate for Payer: Anthem Medicaid |
$64.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.49
|
| Rate for Payer: Cash Price |
$93.26
|
| Rate for Payer: Cigna Commercial |
$154.82
|
| Rate for Payer: First Health Commercial |
$177.20
|
| Rate for Payer: Humana Commercial |
$158.55
|
| Rate for Payer: Humana KY Medicaid |
$64.15
|
| Rate for Payer: Kentucky WC Medicaid |
$64.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.15
|
| Rate for Payer: Ohio Health Group HMO |
$139.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.71
|
| Rate for Payer: PHCS Commercial |
$179.07
|
| Rate for Payer: United Healthcare All Payer |
$164.15
|
|
|
BREVITAL (METHO 500MG/50ML
|
Facility
|
IP
|
$186.53
|
|
|
Service Code
|
NDC 42023010501
|
| Hospital Charge Code |
25003855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.96 |
| Max. Negotiated Rate |
$179.07 |
| Rate for Payer: Aetna Commercial |
$143.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.49
|
| Rate for Payer: Cash Price |
$93.26
|
| Rate for Payer: Cigna Commercial |
$154.82
|
| Rate for Payer: First Health Commercial |
$177.20
|
| Rate for Payer: Humana Commercial |
$158.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.15
|
| Rate for Payer: Ohio Health Group HMO |
$139.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.71
|
| Rate for Payer: PHCS Commercial |
$179.07
|
| Rate for Payer: United Healthcare All Payer |
$164.15
|
|
|
BRIDION 200 MG/2ML VIAL
|
Facility
|
IP
|
$551.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002905
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$165.45 |
| Max. Negotiated Rate |
$529.44 |
| Rate for Payer: Aetna Commercial |
$424.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$430.17
|
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Cigna Commercial |
$457.75
|
| Rate for Payer: First Health Commercial |
$523.92
|
| Rate for Payer: Humana Commercial |
$468.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$452.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$407.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$485.32
|
| Rate for Payer: Ohio Health Group HMO |
$413.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$441.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$479.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$380.54
|
| Rate for Payer: PHCS Commercial |
$529.44
|
| Rate for Payer: United Healthcare All Payer |
$485.32
|
|
|
BRIDION 200 MG/2ML VIAL
|
Facility
|
OP
|
$551.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002905
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$165.45 |
| Max. Negotiated Rate |
$529.44 |
| Rate for Payer: Aetna Commercial |
$424.65
|
| Rate for Payer: Anthem Medicaid |
$189.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$430.17
|
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Cigna Commercial |
$457.75
|
| Rate for Payer: First Health Commercial |
$523.92
|
| Rate for Payer: Humana Commercial |
$468.77
|
| Rate for Payer: Humana KY Medicaid |
$189.66
|
| Rate for Payer: Kentucky WC Medicaid |
$191.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$452.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$407.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$193.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$485.32
|
| Rate for Payer: Ohio Health Group HMO |
$413.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$441.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$479.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$380.54
|
| Rate for Payer: PHCS Commercial |
$529.44
|
| Rate for Payer: United Healthcare All Payer |
$485.32
|
|
|
BRIDION 500 MG/5ML VIAL
|
Facility
|
IP
|
$654.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002906
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$196.26 |
| Max. Negotiated Rate |
$628.03 |
| Rate for Payer: Aetna Commercial |
$503.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.28
|
| Rate for Payer: Cash Price |
$327.10
|
| Rate for Payer: Cigna Commercial |
$542.99
|
| Rate for Payer: First Health Commercial |
$621.49
|
| Rate for Payer: Humana Commercial |
$556.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$536.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$482.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$575.70
|
| Rate for Payer: Ohio Health Group HMO |
$490.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$451.40
|
| Rate for Payer: PHCS Commercial |
$628.03
|
| Rate for Payer: United Healthcare All Payer |
$575.70
|
|
|
BRIDION 500 MG/5ML VIAL
|
Facility
|
OP
|
$654.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002906
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$196.26 |
| Max. Negotiated Rate |
$628.03 |
| Rate for Payer: Aetna Commercial |
$503.73
|
| Rate for Payer: Anthem Medicaid |
$224.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.28
|
| Rate for Payer: Cash Price |
$327.10
|
| Rate for Payer: Cigna Commercial |
$542.99
|
| Rate for Payer: First Health Commercial |
$621.49
|
| Rate for Payer: Humana Commercial |
$556.07
|
| Rate for Payer: Humana KY Medicaid |
$224.98
|
| Rate for Payer: Kentucky WC Medicaid |
$227.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$536.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$482.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$229.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$575.70
|
| Rate for Payer: Ohio Health Group HMO |
$490.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$451.40
|
| Rate for Payer: PHCS Commercial |
$628.03
|
| Rate for Payer: United Healthcare All Payer |
$575.70
|
|
|
Brief check in by md/qhp
|
Professional
|
Both
|
$50.00
|
|
| Hospital Charge Code |
51000021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
|
|
Brief check in by md/qhp
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
51000021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
Brief check in by md/qhp
|
Professional
|
Both
|
$21.00
|
|
| Hospital Charge Code |
510P0021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$14.70 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Multiplan PHCS |
$12.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.70
|
| Rate for Payer: UHCCP Medicaid |
$7.35
|
|
|
Brief check in by md/qhp
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
510T0021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$27.84 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.62
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cigna Commercial |
$24.07
|
| Rate for Payer: First Health Commercial |
$27.55
|
| Rate for Payer: Humana Commercial |
$24.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.52
|
| Rate for Payer: Ohio Health Group HMO |
$21.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.01
|
| Rate for Payer: PHCS Commercial |
$27.84
|
| Rate for Payer: United Healthcare All Payer |
$25.52
|
|
|
Brief check in by md/qhp
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
51000021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem Medicaid |
$17.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Humana KY Medicaid |
$17.20
|
| Rate for Payer: Kentucky WC Medicaid |
$17.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
Brief check in by md/qhp
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
510T0021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$27.84 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Anthem Medicaid |
$9.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.62
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cigna Commercial |
$24.07
|
| Rate for Payer: First Health Commercial |
$27.55
|
| Rate for Payer: Humana Commercial |
$24.65
|
| Rate for Payer: Humana KY Medicaid |
$9.97
|
| Rate for Payer: Kentucky WC Medicaid |
$10.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.52
|
| Rate for Payer: Ohio Health Group HMO |
$21.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.01
|
| Rate for Payer: PHCS Commercial |
$27.84
|
| Rate for Payer: United Healthcare All Payer |
$25.52
|
|
|
BRIEF COMUNICAJ TECH-BSD SVC
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 98016
|
| Hospital Charge Code |
96000050
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Ambetter Exchange |
$14.20
|
| Rate for Payer: Anthem Medicaid |
$13.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$14.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$14.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.04
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Humana Medicaid |
$13.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$14.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$13.79
|
| Rate for Payer: Molina Healthcare Passport |
$13.52
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$18.46
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$13.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$14.20
|
|
|
BRIEF COMUNICAJ TECH-BSD SVC
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 98016
|
| Hospital Charge Code |
96000050
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$13.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Humana KY Medicaid |
$13.76
|
| Rate for Payer: Kentucky WC Medicaid |
$13.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
BRIEF COMUNICAJ TECH-BSD SVC
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 98016
|
| Hospital Charge Code |
96000050
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
51000048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$103.68 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.24
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$89.64
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: Humana Commercial |
$91.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.04
|
| Rate for Payer: Ohio Health Group HMO |
$81.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.52
|
| Rate for Payer: PHCS Commercial |
$103.68
|
| Rate for Payer: United Healthcare All Payer |
$95.04
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
51000048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Ambetter Exchange |
$4.16
|
| Rate for Payer: Anthem Medicaid |
$3.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.99
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$7.20
|
| Rate for Payer: Humana Medicaid |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3.94
|
| Rate for Payer: Molina Healthcare Passport |
$3.86
|
| Rate for Payer: Multiplan PHCS |
$64.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.41
|
| Rate for Payer: UHCCP Medicaid |
$37.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.16
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
51000048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$103.68 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Anthem Medicaid |
$37.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.96
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$89.64
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: Humana Commercial |
$91.80
|
| Rate for Payer: Humana KY Medicaid |
$37.14
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$37.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.04
|
| Rate for Payer: Ohio Health Group HMO |
$81.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.52
|
| Rate for Payer: PHCS Commercial |
$103.68
|
| Rate for Payer: United Healthcare All Payer |
$95.04
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT(P
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
510P0048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Ambetter Exchange |
$4.16
|
| Rate for Payer: Anthem Medicaid |
$3.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.99
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$7.20
|
| Rate for Payer: Humana Medicaid |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3.94
|
| Rate for Payer: Molina Healthcare Passport |
$3.86
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.41
|
| Rate for Payer: UHCCP Medicaid |
$19.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.16
|
|
|
BRIEF EMOTIONAL/BEHAV ASSMT(T
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
510T0048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$50.88 |
| Rate for Payer: Aetna Commercial |
$40.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.34
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$43.99
|
| Rate for Payer: First Health Commercial |
$50.35
|
| Rate for Payer: Humana Commercial |
$45.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$46.64
|
| Rate for Payer: Ohio Health Group HMO |
$39.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.57
|
| Rate for Payer: PHCS Commercial |
$50.88
|
| Rate for Payer: United Healthcare All Payer |
$46.64
|
|
