|
FAN LIME 13X32 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 13X34 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 13X34 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 13X36 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 13X36 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FARXIGA
|
Facility
|
IP
|
$36.41
|
|
|
Service Code
|
NDC 310620530
|
| Hospital Charge Code |
25003057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$28.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.40
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cigna Commercial |
$30.22
|
| Rate for Payer: First Health Commercial |
$34.59
|
| Rate for Payer: Humana Commercial |
$30.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.04
|
| Rate for Payer: Ohio Health Group HMO |
$27.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.29
|
| Rate for Payer: PHCS Commercial |
$34.95
|
| Rate for Payer: United Healthcare All Payer |
$32.04
|
|
|
FARXIGA
|
Facility
|
OP
|
$36.41
|
|
|
Service Code
|
NDC 310620530
|
| Hospital Charge Code |
25003057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$28.04
|
| Rate for Payer: Anthem Medicaid |
$12.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.40
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cigna Commercial |
$30.22
|
| Rate for Payer: First Health Commercial |
$34.59
|
| Rate for Payer: Humana Commercial |
$30.95
|
| Rate for Payer: Humana KY Medicaid |
$12.52
|
| Rate for Payer: Kentucky WC Medicaid |
$12.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.04
|
| Rate for Payer: Ohio Health Group HMO |
$27.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.29
|
| Rate for Payer: PHCS Commercial |
$34.95
|
| Rate for Payer: United Healthcare All Payer |
$32.04
|
|
|
FARZIGA 10 MG TABLET
|
Facility
|
IP
|
$36.41
|
|
|
Service Code
|
NDC 310621030
|
| Hospital Charge Code |
25000663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$28.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.40
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cigna Commercial |
$30.22
|
| Rate for Payer: First Health Commercial |
$34.59
|
| Rate for Payer: Humana Commercial |
$30.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.04
|
| Rate for Payer: Ohio Health Group HMO |
$27.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.29
|
| Rate for Payer: PHCS Commercial |
$34.95
|
| Rate for Payer: United Healthcare All Payer |
$32.04
|
|
|
FARZIGA 10 MG TABLET
|
Facility
|
OP
|
$36.41
|
|
|
Service Code
|
NDC 310621030
|
| Hospital Charge Code |
25000663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$28.04
|
| Rate for Payer: Anthem Medicaid |
$12.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.40
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cigna Commercial |
$30.22
|
| Rate for Payer: First Health Commercial |
$34.59
|
| Rate for Payer: Humana Commercial |
$30.95
|
| Rate for Payer: Humana KY Medicaid |
$12.52
|
| Rate for Payer: Kentucky WC Medicaid |
$12.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.04
|
| Rate for Payer: Ohio Health Group HMO |
$27.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.29
|
| Rate for Payer: PHCS Commercial |
$34.95
|
| Rate for Payer: United Healthcare All Payer |
$32.04
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
IP
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
76100674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.60 |
| Max. Negotiated Rate |
$883.20 |
| Rate for Payer: Aetna Commercial |
$708.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$717.60
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$763.60
|
| Rate for Payer: First Health Commercial |
$874.00
|
| Rate for Payer: Humana Commercial |
$782.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$754.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$678.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$809.60
|
| Rate for Payer: Ohio Health Group HMO |
$690.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$119.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$285.20
|
| Rate for Payer: PHCS Commercial |
$883.20
|
| Rate for Payer: United Healthcare All Payer |
$809.60
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
761P0674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.48 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: Aetna Commercial |
$428.84
|
| Rate for Payer: Anthem Medicaid |
$216.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$920.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$465.14
|
| Rate for Payer: Healthspan PPO |
$388.44
|
| Rate for Payer: Humana Medicaid |
$216.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$350.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$220.81
|
| Rate for Payer: Molina Healthcare Passport |
$216.48
|
| Rate for Payer: Multiplan PHCS |
$552.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$644.00
|
| Rate for Payer: UHCCP Medicaid |
$322.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$218.64
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
OP
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
76100674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.60 |
| Max. Negotiated Rate |
$883.20 |
| Rate for Payer: Aetna Commercial |
$708.40
|
| Rate for Payer: Anthem Medicaid |
$316.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$717.60
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$763.60
|
| Rate for Payer: First Health Commercial |
$874.00
|
| Rate for Payer: Humana Commercial |
$782.00
|
| Rate for Payer: Humana KY Medicaid |
$316.39
|
| Rate for Payer: Kentucky WC Medicaid |
$319.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$754.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$678.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$322.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$809.60
|
| Rate for Payer: Ohio Health Group HMO |
$690.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$119.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$285.20
|
| Rate for Payer: PHCS Commercial |
$883.20
|
| Rate for Payer: United Healthcare All Payer |
$809.60
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
IP
|
$1,656.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
45000135
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$215.28 |
| Max. Negotiated Rate |
$1,589.76 |
| Rate for Payer: Aetna Commercial |
$1,275.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,291.68
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$1,374.48
|
| Rate for Payer: First Health Commercial |
$1,573.20
|
| Rate for Payer: Humana Commercial |
$1,407.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,357.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,222.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$496.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,457.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,242.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$331.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$215.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$513.36
|
| Rate for Payer: PHCS Commercial |
$1,589.76
|
| Rate for Payer: United Healthcare All Payer |
$1,457.28
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Facility
|
OP
|
$1,656.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
45000135
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$215.28 |
| Max. Negotiated Rate |
$1,589.76 |
| Rate for Payer: Aetna Commercial |
$1,275.12
|
| Rate for Payer: Anthem Medicaid |
$569.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,291.68
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$1,374.48
|
| Rate for Payer: First Health Commercial |
$1,573.20
|
| Rate for Payer: Humana Commercial |
$1,407.60
|
| Rate for Payer: Humana KY Medicaid |
$569.50
|
| Rate for Payer: Kentucky WC Medicaid |
$575.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,357.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,222.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$496.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$580.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,457.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,242.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$331.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$215.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$513.36
|
| Rate for Payer: PHCS Commercial |
$1,589.76
|
| Rate for Payer: United Healthcare All Payer |
$1,457.28
|
|
|
FASCECTMYPRTLPALMARSNGLDIGADTL
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
76100674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.48 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: Aetna Commercial |
$428.84
|
| Rate for Payer: Anthem Medicaid |
$216.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$920.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$465.14
|
| Rate for Payer: Healthspan PPO |
$388.44
|
| Rate for Payer: Humana Medicaid |
$216.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$350.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$220.81
|
| Rate for Payer: Molina Healthcare Passport |
$216.48
|
| Rate for Payer: Multiplan PHCS |
$552.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$644.00
|
| Rate for Payer: UHCCP Medicaid |
$322.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$218.64
|
|
|
FASCIA LATA 4*7CM
|
Facility
|
IP
|
$10,600.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,378.00 |
| Max. Negotiated Rate |
$10,176.00 |
| Rate for Payer: Aetna Commercial |
$8,162.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,268.00
|
| Rate for Payer: Cash Price |
$5,300.00
|
| Rate for Payer: Cigna Commercial |
$8,798.00
|
| Rate for Payer: First Health Commercial |
$10,070.00
|
| Rate for Payer: Humana Commercial |
$9,010.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,692.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,822.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,328.00
|
| Rate for Payer: Ohio Health Group HMO |
$7,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,378.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,286.00
|
| Rate for Payer: PHCS Commercial |
$10,176.00
|
| Rate for Payer: United Healthcare All Payer |
$9,328.00
|
|
|
FASCIA LATA 4*7CM
|
Facility
|
OP
|
$10,600.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,378.00 |
| Max. Negotiated Rate |
$10,176.00 |
| Rate for Payer: Aetna Commercial |
$8,162.00
|
| Rate for Payer: Anthem Medicaid |
$3,645.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,268.00
|
| Rate for Payer: Cash Price |
$5,300.00
|
| Rate for Payer: Cigna Commercial |
$8,798.00
|
| Rate for Payer: First Health Commercial |
$10,070.00
|
| Rate for Payer: Humana Commercial |
$9,010.00
|
| Rate for Payer: Humana KY Medicaid |
$3,645.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,682.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,692.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,822.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,718.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,328.00
|
| Rate for Payer: Ohio Health Group HMO |
$7,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,378.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,286.00
|
| Rate for Payer: PHCS Commercial |
$10,176.00
|
| Rate for Payer: United Healthcare All Payer |
$9,328.00
|
|
|
FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
FASCIECTOMY, PLANTAR FASCIA; RADICAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28062
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
FASCIOTOMY, FOOT AND/OR TOE
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28008
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
FASCIOTOMY, FOOT AND/OR TOE
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
HCPCS 28008
|
| Hospital Charge Code |
76100967
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$475.20 |
| Rate for Payer: Aetna Commercial |
$381.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$386.10
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$410.85
|
| Rate for Payer: First Health Commercial |
$470.25
|
| Rate for Payer: Humana Commercial |
$420.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$365.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$435.60
|
| Rate for Payer: Ohio Health Group HMO |
$371.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.45
|
| Rate for Payer: PHCS Commercial |
$475.20
|
| Rate for Payer: United Healthcare All Payer |
$435.60
|
|
|
FASCIOTOMY, FOOT AND/OR TOE
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
HCPCS 28008
|
| Hospital Charge Code |
76100967
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$381.15
|
| Rate for Payer: Anthem Medicaid |
$170.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$386.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$410.85
|
| Rate for Payer: First Health Commercial |
$470.25
|
| Rate for Payer: Humana Commercial |
$420.75
|
| Rate for Payer: Humana KY Medicaid |
$170.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$171.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$365.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$173.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$435.60
|
| Rate for Payer: Ohio Health Group HMO |
$371.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.45
|
| Rate for Payer: PHCS Commercial |
$475.20
|
| Rate for Payer: United Healthcare All Payer |
$435.60
|
|
|
FASCIOTOMY, FOOT AND/OR TOE
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28008
|
| Hospital Charge Code |
76100967
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
FASCIOTOMY, FOOT AND/OR TOE
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
HCPCS 28008
|
| Hospital Charge Code |
76100967
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.67 |
| Max. Negotiated Rate |
$543.05 |
| Rate for Payer: Aetna Commercial |
$460.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$149.67
|
| Rate for Payer: Anthem Medicaid |
$201.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$495.00
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$504.43
|
| Rate for Payer: Healthspan PPO |
$543.05
|
| Rate for Payer: Humana Medicaid |
$201.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$365.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$205.92
|
| Rate for Payer: Molina Healthcare Passport |
$201.88
|
| Rate for Payer: Multiplan PHCS |
$297.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$346.50
|
| Rate for Payer: UHCCP Medicaid |
$157.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$203.90
|
|
|
FASCIOTOMY, FOOT AND/OR TOE(P
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
HCPCS 28008
|
| Hospital Charge Code |
761P0967
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.67 |
| Max. Negotiated Rate |
$543.05 |
| Rate for Payer: Aetna Commercial |
$460.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$149.67
|
| Rate for Payer: Anthem Medicaid |
$201.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$495.00
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$504.43
|
| Rate for Payer: Healthspan PPO |
$543.05
|
| Rate for Payer: Humana Medicaid |
$201.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$365.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$205.92
|
| Rate for Payer: Molina Healthcare Passport |
$201.88
|
| Rate for Payer: Multiplan PHCS |
$297.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$346.50
|
| Rate for Payer: UHCCP Medicaid |
$157.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$203.90
|
|
