|
EXELON (RIVASTIGMINE) 3 MG TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 62332006460
|
| Hospital Charge Code |
25000649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
EXELON (RIVASTIGMINE) 3 MG TAB
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 62332006460
|
| Hospital Charge Code |
25000649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
EXERCISE TEST BRONCHOSPASM
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$391.68 |
| Rate for Payer: Aetna Commercial |
$314.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$318.24
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$338.64
|
| Rate for Payer: First Health Commercial |
$387.60
|
| Rate for Payer: Humana Commercial |
$346.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$334.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$301.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$359.04
|
| Rate for Payer: Ohio Health Group HMO |
$306.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.48
|
| Rate for Payer: PHCS Commercial |
$391.68
|
| Rate for Payer: United Healthcare All Payer |
$359.04
|
|
|
EXERCISE TEST BRONCHOSPASM
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$391.68 |
| Rate for Payer: Aetna Commercial |
$314.16
|
| Rate for Payer: Anthem Medicaid |
$140.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$318.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$338.64
|
| Rate for Payer: First Health Commercial |
$387.60
|
| Rate for Payer: Humana Commercial |
$346.80
|
| Rate for Payer: Humana KY Medicaid |
$140.31
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$141.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$334.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$301.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$143.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$359.04
|
| Rate for Payer: Ohio Health Group HMO |
$306.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.48
|
| Rate for Payer: PHCS Commercial |
$391.68
|
| Rate for Payer: United Healthcare All Payer |
$359.04
|
|
|
EXERCISE TEST BRONCHOSPASM
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Anthem Medicaid |
$72.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$408.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$151.27
|
| Rate for Payer: Humana Medicaid |
$72.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.81
|
| Rate for Payer: Molina Healthcare Passport |
$72.36
|
| Rate for Payer: Multiplan PHCS |
$244.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$285.60
|
| Rate for Payer: UHCCP Medicaid |
$142.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.08
|
|
|
EXERCISE TEST BRONCHOSPASM (P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
460P0027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Anthem Medicaid |
$72.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$151.27
|
| Rate for Payer: Humana Medicaid |
$72.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.81
|
| Rate for Payer: Molina Healthcare Passport |
$72.36
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.08
|
|
|
EXERCISE TEST BRONCHOSPASM (T
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
460T0027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
EXERCISE TEST BRONCHOSPASM (T
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
460T0027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
42000017
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Humana KY Medicaid |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
43000012
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Humana KY Medicaid |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
42000017
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
43000012
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
EXERCISE TST BRNCSPSM
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000005
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
EXERCISE TST BRNCSPSM
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000005
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
EXERCISE TST BRNCSPSM WO ECG
|
Facility
|
OP
|
$46.05
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
46000028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$74.05 |
| Rate for Payer: Aetna Commercial |
$35.46
|
| Rate for Payer: Anthem Medicaid |
$15.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cigna Commercial |
$38.22
|
| Rate for Payer: First Health Commercial |
$43.75
|
| Rate for Payer: Humana Commercial |
$39.14
|
| Rate for Payer: Humana KY Medicaid |
$15.84
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$16.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$37.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$40.52
|
| Rate for Payer: Ohio Health Group HMO |
$34.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.28
|
| Rate for Payer: PHCS Commercial |
$44.21
|
| Rate for Payer: United Healthcare All Payer |
$40.52
|
|
|
EXERCISE TST BRNCSPSM WO ECG
|
Facility
|
IP
|
$46.05
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
46000028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$44.21 |
| Rate for Payer: Aetna Commercial |
$35.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.92
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cigna Commercial |
$38.22
|
| Rate for Payer: First Health Commercial |
$43.75
|
| Rate for Payer: Humana Commercial |
$39.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$37.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$40.52
|
| Rate for Payer: Ohio Health Group HMO |
$34.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.28
|
| Rate for Payer: PHCS Commercial |
$44.21
|
| Rate for Payer: United Healthcare All Payer |
$40.52
|
|
|
EXERCISE TST BRNCSPSM WO ECG
|
Professional
|
Both
|
$46.05
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
46000028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$58.25 |
| Rate for Payer: Anthem Medicaid |
$57.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$46.05
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Humana Medicaid |
$57.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.25
|
| Rate for Payer: Molina Healthcare Passport |
$57.11
|
| Rate for Payer: Multiplan PHCS |
$27.63
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$32.24
|
| Rate for Payer: UHCCP Medicaid |
$16.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.68
|
|
|
EXERCISE TST BRNCSPSM WO ECG(P
|
Professional
|
Both
|
$21.05
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
460P0028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$58.25 |
| Rate for Payer: Anthem Medicaid |
$57.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$21.05
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Humana Medicaid |
$57.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.25
|
| Rate for Payer: Molina Healthcare Passport |
$57.11
|
| Rate for Payer: Multiplan PHCS |
$12.63
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.74
|
| Rate for Payer: UHCCP Medicaid |
$7.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.68
|
|
|
EXERCISE TST BRNCSPSM WO ECG(T
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
460T0028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.75
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
EXERCISE TST BRNCSPSM WO ECG(T
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
460T0028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$74.05 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem Medicaid |
$8.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Humana KY Medicaid |
$8.60
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$8.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.75
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
EXFOLIATE CLEANSER 200ML GBL
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
22200140
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
EXFOLIATING POLISH
|
Professional
|
Both
|
$67.00
|
|
| Hospital Charge Code |
22200161
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$23.45 |
| Max. Negotiated Rate |
$67.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$67.00
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Multiplan PHCS |
$40.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.90
|
| Rate for Payer: UHCCP Medicaid |
$23.45
|
|
|
EX FOR SPEECH DEVICE RX ADDL
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 92608
|
| Hospital Charge Code |
44000011
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.20
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
EX FOR SPEECH DEVICE RX ADDL
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 92608
|
| Hospital Charge Code |
44000011
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.20
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
76100896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$1,962.83 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
