|
EXELON 9.5MG/24HR PATCH
|
Facility
|
OP
|
$30.52
|
|
|
Service Code
|
NDC 781730931
|
| Hospital Charge Code |
25000652
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$23.50
|
| Rate for Payer: Anthem Medicaid |
$10.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.81
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cigna Commercial |
$25.33
|
| Rate for Payer: First Health Commercial |
$28.99
|
| Rate for Payer: Humana Commercial |
$25.94
|
| Rate for Payer: Humana KY Medicaid |
$10.50
|
| Rate for Payer: Kentucky WC Medicaid |
$10.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.86
|
| Rate for Payer: Ohio Health Group HMO |
$22.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.06
|
| Rate for Payer: PHCS Commercial |
$29.30
|
| Rate for Payer: United Healthcare All Payer |
$26.86
|
|
|
EXELON 9.5MG/24HR PATCH
|
Facility
|
IP
|
$30.52
|
|
|
Service Code
|
NDC 781730931
|
| Hospital Charge Code |
25000652
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$23.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.81
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cigna Commercial |
$25.33
|
| Rate for Payer: First Health Commercial |
$28.99
|
| Rate for Payer: Humana Commercial |
$25.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.86
|
| Rate for Payer: Ohio Health Group HMO |
$22.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.06
|
| Rate for Payer: PHCS Commercial |
$29.30
|
| Rate for Payer: United Healthcare All Payer |
$26.86
|
|
|
EXELON (RIVASTIGMINE) 1.5 MG T
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 55111035260
|
| Hospital Charge Code |
25000648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| 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 |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
EXELON (RIVASTIGMINE) 1.5 MG T
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 55111035260
|
| Hospital Charge Code |
25000648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| 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 |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| 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 |
$1.43 |
| 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 |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
EXELON (RIVASTIGMINE) 3 MG TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 62332006460
|
| Hospital Charge Code |
25000649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| 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 |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
EXERCISE TEST BRONCHOSPASM
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$124.20 |
| Max. Negotiated Rate |
$397.44 |
| Rate for Payer: Aetna Commercial |
$318.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$322.92
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$343.62
|
| Rate for Payer: First Health Commercial |
$393.30
|
| Rate for Payer: Humana Commercial |
$351.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$339.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$305.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$364.32
|
| Rate for Payer: Ohio Health Group HMO |
$310.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$331.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$360.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$285.66
|
| Rate for Payer: PHCS Commercial |
$397.44
|
| Rate for Payer: United Healthcare All Payer |
$364.32
|
|
|
EXERCISE TEST BRONCHOSPASM
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$397.44 |
| Rate for Payer: Aetna Commercial |
$318.78
|
| Rate for Payer: Anthem Medicaid |
$142.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$322.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$343.62
|
| Rate for Payer: First Health Commercial |
$393.30
|
| Rate for Payer: Humana Commercial |
$351.90
|
| Rate for Payer: Humana KY Medicaid |
$142.37
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$143.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$339.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$305.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$364.32
|
| Rate for Payer: Ohio Health Group HMO |
$310.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$331.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$360.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$285.66
|
| Rate for Payer: PHCS Commercial |
$397.44
|
| Rate for Payer: United Healthcare All Payer |
$364.32
|
|
|
EXERCISE TEST BRONCHOSPASM
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Ambetter Exchange |
$81.15
|
| Rate for Payer: Anthem Medicaid |
$72.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$81.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$81.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$97.38
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$81.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.81
|
| Rate for Payer: Molina Healthcare Passport |
$72.36
|
| Rate for Payer: Multiplan PHCS |
$248.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.50
|
| Rate for Payer: UHCCP Medicaid |
$144.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$81.15
|
|
|
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 |
$151.27 |
| Rate for Payer: Ambetter Exchange |
$81.15
|
| Rate for Payer: Anthem Medicaid |
$72.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$81.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$81.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$97.38
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$81.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.15
|
| 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 |
$105.50
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$81.15
|
|
|
EXERCISE TEST BRONCHOSPASM (T
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
460T0027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$61.56 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem Medicaid |
$61.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Humana KY Medicaid |
$61.56
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$62.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
EXERCISE TEST BRONCHOSPASM (T
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
460T0027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
42000017
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$148.80 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem Medicaid |
$53.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Humana KY Medicaid |
$53.30
|
| Rate for Payer: Kentucky WC Medicaid |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
43000012
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$148.80 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem Medicaid |
$53.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Humana KY Medicaid |
$53.30
|
| Rate for Payer: Kentucky WC Medicaid |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
42000017
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$148.80 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
EXERCISE - THERAPEUTIC 15 MIN
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
43000012
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$148.80 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
EXERCISE TST BRNCSPSM
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 94617
|
| Hospital Charge Code |
46000005
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$51.90 |
| 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 |
$138.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$119.37
|
| 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 |
$59.49 |
| Max. Negotiated Rate |
$166.74 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| 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 |
$119.10
|
| 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 |
$142.92
|
| 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 |
$138.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$119.37
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
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 |
$77.08 |
| Rate for Payer: Ambetter Exchange |
$59.29
|
| Rate for Payer: Anthem Medicaid |
$57.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$59.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$59.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.15
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Humana Medicaid |
$57.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$59.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.29
|
| 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 |
$77.08
|
| Rate for Payer: UHCCP Medicaid |
$16.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$59.29
|
|
|
EXERCISE TST BRNCSPSM WO ECG
|
Facility
|
IP
|
$46.05
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
46000028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$13.81 |
| 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 |
$13.81
|
| 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 |
$36.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$40.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.77
|
| Rate for Payer: PHCS Commercial |
$44.21
|
| Rate for Payer: United Healthcare All Payer |
$40.52
|
|
|
EXERCISE TST BRNCSPSM WO ECG
|
Facility
|
OP
|
$46.05
|
|
|
Service Code
|
HCPCS 94619
|
| Hospital Charge Code |
46000028
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$76.83 |
| Rate for Payer: Aetna Commercial |
$35.46
|
| Rate for Payer: Anthem Medicaid |
$15.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| 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 |
$54.88
|
| 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 |
$65.86
|
| 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 |
$36.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$40.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.77
|
| Rate for Payer: PHCS Commercial |
$44.21
|
| Rate for Payer: United Healthcare All Payer |
$40.52
|
|
|
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 |
$77.08 |
| Rate for Payer: Ambetter Exchange |
$59.29
|
| Rate for Payer: Anthem Medicaid |
$57.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$59.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$59.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.15
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Humana Medicaid |
$57.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$59.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.29
|
| 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 |
$77.08
|
| Rate for Payer: UHCCP Medicaid |
$7.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$59.29
|
|
|
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 |
$8.60 |
| Max. Negotiated Rate |
$76.83 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem Medicaid |
$8.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| 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 |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$8.69
|
| 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 |
$65.86
|
| 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 |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
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 |
$7.50 |
| 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 |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
EXFOLIATE CLEANSER 200ML GBL
|
Facility
|
OP
|
$45.00
|
|
| Hospital Charge Code |
22200140
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
