|
FATHOM 16 PRELOAD
|
Facility
|
IP
|
$4,356.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.28 |
| Max. Negotiated Rate |
$4,181.76 |
| Rate for Payer: Aetna Commercial |
$3,354.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,397.68
|
| Rate for Payer: Cash Price |
$2,178.00
|
| Rate for Payer: Cigna Commercial |
$3,615.48
|
| Rate for Payer: First Health Commercial |
$4,138.20
|
| Rate for Payer: Humana Commercial |
$3,702.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,571.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,214.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,306.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,833.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,267.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$871.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$566.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,350.36
|
| Rate for Payer: PHCS Commercial |
$4,181.76
|
| Rate for Payer: United Healthcare All Payer |
$3,833.28
|
|
|
FAT W/FACELIFT ORTH COSMEC PX
|
Professional
|
Both
|
$500.00
|
|
| Hospital Charge Code |
22200089
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
|
|
FAT W/FACELIFT OTH COSM PX-80
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200385
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
76102381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.01 |
| Max. Negotiated Rate |
$553.92 |
| Rate for Payer: Aetna Commercial |
$444.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.06
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cigna Commercial |
$478.91
|
| Rate for Payer: First Health Commercial |
$548.15
|
| Rate for Payer: Humana Commercial |
$490.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$425.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$507.76
|
| Rate for Payer: Ohio Health Group HMO |
$432.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.87
|
| Rate for Payer: PHCS Commercial |
$553.92
|
| Rate for Payer: United Healthcare All Payer |
$507.76
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
45000297
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$270.72 |
| Rate for Payer: Aetna Commercial |
$217.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$219.96
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$234.06
|
| Rate for Payer: First Health Commercial |
$267.90
|
| Rate for Payer: Humana Commercial |
$239.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$231.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$208.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$248.16
|
| Rate for Payer: Ohio Health Group HMO |
$211.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$270.72
|
| Rate for Payer: United Healthcare All Payer |
$248.16
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
45000297
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$270.72 |
| Rate for Payer: Aetna Commercial |
$217.14
|
| Rate for Payer: Anthem Medicaid |
$96.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$219.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$234.06
|
| Rate for Payer: First Health Commercial |
$267.90
|
| Rate for Payer: Humana Commercial |
$239.70
|
| Rate for Payer: Humana KY Medicaid |
$96.98
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$97.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$231.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$208.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$98.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$248.16
|
| Rate for Payer: Ohio Health Group HMO |
$211.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$87.42
|
| Rate for Payer: PHCS Commercial |
$270.72
|
| Rate for Payer: United Healthcare All Payer |
$248.16
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
76102381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.15 |
| Max. Negotiated Rate |
$577.00 |
| Rate for Payer: Aetna Commercial |
$60.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.15
|
| Rate for Payer: Anthem Medicaid |
$28.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$577.00
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cigna Commercial |
$74.23
|
| Rate for Payer: Healthspan PPO |
$66.27
|
| Rate for Payer: Humana Medicaid |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.91
|
| Rate for Payer: Molina Healthcare Passport |
$28.34
|
| Rate for Payer: Multiplan PHCS |
$346.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$403.90
|
| Rate for Payer: UHCCP Medicaid |
$27.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.62
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
76102381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.01 |
| Max. Negotiated Rate |
$553.92 |
| Rate for Payer: Aetna Commercial |
$444.29
|
| Rate for Payer: Anthem Medicaid |
$198.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cigna Commercial |
$478.91
|
| Rate for Payer: First Health Commercial |
$548.15
|
| Rate for Payer: Humana Commercial |
$490.45
|
| Rate for Payer: Humana KY Medicaid |
$198.43
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$200.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$425.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$202.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$507.76
|
| Rate for Payer: Ohio Health Group HMO |
$432.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.87
|
| Rate for Payer: PHCS Commercial |
$553.92
|
| Rate for Payer: United Healthcare All Payer |
$507.76
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL(P
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
761P2381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.15 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$60.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.15
|
| Rate for Payer: Anthem Medicaid |
$28.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$240.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$74.23
|
| Rate for Payer: Healthspan PPO |
$66.27
|
| Rate for Payer: Humana Medicaid |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.91
|
| Rate for Payer: Molina Healthcare Passport |
$28.34
|
| Rate for Payer: Multiplan PHCS |
$144.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$168.00
|
| Rate for Payer: UHCCP Medicaid |
$27.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.62
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL(T
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
761T2381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.81 |
| Max. Negotiated Rate |
$323.52 |
| Rate for Payer: Aetna Commercial |
$259.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.86
|
| Rate for Payer: Cash Price |
$168.50
|
| Rate for Payer: Cigna Commercial |
$279.71
|
| Rate for Payer: First Health Commercial |
$320.15
|
| Rate for Payer: Humana Commercial |
$286.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$276.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$248.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$296.56
|
| Rate for Payer: Ohio Health Group HMO |
$252.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.47
|
| Rate for Payer: PHCS Commercial |
$323.52
|
| Rate for Payer: United Healthcare All Payer |
$296.56
|
|
|
FBR CONJUNCTIVAL SUPERFICIAL(T
|
Facility
|
OP
|
$337.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
761T2381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.81 |
| Max. Negotiated Rate |
$323.52 |
| Rate for Payer: Aetna Commercial |
$259.49
|
| Rate for Payer: Anthem Medicaid |
$115.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$168.50
|
| Rate for Payer: Cash Price |
$168.50
|
| Rate for Payer: Cigna Commercial |
$279.71
|
| Rate for Payer: First Health Commercial |
$320.15
|
| Rate for Payer: Humana Commercial |
$286.45
|
| Rate for Payer: Humana KY Medicaid |
$115.89
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$117.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$276.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$248.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$118.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$296.56
|
| Rate for Payer: Ohio Health Group HMO |
$252.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.47
|
| Rate for Payer: PHCS Commercial |
$323.52
|
| Rate for Payer: United Healthcare All Payer |
$296.56
|
|
|
FBR FOOT SUBCUTANIOUS
|
Professional
|
Both
|
$2,238.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
76100989
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.23 |
| Max. Negotiated Rate |
$2,238.00 |
| Rate for Payer: Aetna Commercial |
$202.76
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$74.17
|
| Rate for Payer: Anthem Medicaid |
$64.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,238.00
|
| Rate for Payer: Cash Price |
$1,119.00
|
| Rate for Payer: Cash Price |
$1,119.00
|
| Rate for Payer: Cigna Commercial |
$354.18
|
| Rate for Payer: Healthspan PPO |
$300.98
|
| Rate for Payer: Humana Medicaid |
$64.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$165.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.51
|
| Rate for Payer: Molina Healthcare Passport |
$64.23
|
| Rate for Payer: Multiplan PHCS |
$1,342.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,566.60
|
| Rate for Payer: UHCCP Medicaid |
$77.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.87
|
|
|
FBR FOOT SUBCUTANIOUS
|
Facility
|
IP
|
$1,281.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
45000173
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$166.53 |
| Max. Negotiated Rate |
$1,229.76 |
| Rate for Payer: Aetna Commercial |
$986.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$999.18
|
| Rate for Payer: Cash Price |
$640.50
|
| Rate for Payer: Cigna Commercial |
$1,063.23
|
| Rate for Payer: First Health Commercial |
$1,216.95
|
| Rate for Payer: Humana Commercial |
$1,088.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,050.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$945.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$384.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,127.28
|
| Rate for Payer: Ohio Health Group HMO |
$960.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$397.11
|
| Rate for Payer: PHCS Commercial |
$1,229.76
|
| Rate for Payer: United Healthcare All Payer |
$1,127.28
|
|
|
FBR FOOT SUBCUTANIOUS
|
Facility
|
OP
|
$1,281.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
45000173
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$166.53 |
| Max. Negotiated Rate |
$1,229.76 |
| Rate for Payer: Aetna Commercial |
$986.37
|
| Rate for Payer: Anthem Medicaid |
$440.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$999.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$640.50
|
| Rate for Payer: Cash Price |
$640.50
|
| Rate for Payer: Cigna Commercial |
$1,063.23
|
| Rate for Payer: First Health Commercial |
$1,216.95
|
| Rate for Payer: Humana Commercial |
$1,088.85
|
| Rate for Payer: Humana KY Medicaid |
$440.54
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$445.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,050.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$945.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$449.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,127.28
|
| Rate for Payer: Ohio Health Group HMO |
$960.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$397.11
|
| Rate for Payer: PHCS Commercial |
$1,229.76
|
| Rate for Payer: United Healthcare All Payer |
$1,127.28
|
|
|
FBR FOOT SUBCUTANIOUS
|
Facility
|
OP
|
$2,238.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
76100989
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$290.94 |
| Max. Negotiated Rate |
$2,148.48 |
| Rate for Payer: Aetna Commercial |
$1,723.26
|
| Rate for Payer: Anthem Medicaid |
$769.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,745.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,119.00
|
| Rate for Payer: Cash Price |
$1,119.00
|
| Rate for Payer: Cigna Commercial |
$1,857.54
|
| Rate for Payer: First Health Commercial |
$2,126.10
|
| Rate for Payer: Humana Commercial |
$1,902.30
|
| Rate for Payer: Humana KY Medicaid |
$769.65
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$777.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,835.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,651.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$785.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,969.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,678.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$290.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$693.78
|
| Rate for Payer: PHCS Commercial |
$2,148.48
|
| Rate for Payer: United Healthcare All Payer |
$1,969.44
|
|
|
FBR FOOT SUBCUTANIOUS
|
Facility
|
IP
|
$2,238.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
76100989
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$290.94 |
| Max. Negotiated Rate |
$2,148.48 |
| Rate for Payer: Aetna Commercial |
$1,723.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,745.64
|
| Rate for Payer: Cash Price |
$1,119.00
|
| Rate for Payer: Cigna Commercial |
$1,857.54
|
| Rate for Payer: First Health Commercial |
$2,126.10
|
| Rate for Payer: Humana Commercial |
$1,902.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,835.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,651.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$671.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,969.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,678.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$290.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$693.78
|
| Rate for Payer: PHCS Commercial |
$2,148.48
|
| Rate for Payer: United Healthcare All Payer |
$1,969.44
|
|
|
FBR FOOT SUBCUTANIOUS(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
761P0989
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.23 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$202.76
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$74.17
|
| Rate for Payer: Anthem Medicaid |
$64.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$354.18
|
| Rate for Payer: Healthspan PPO |
$300.98
|
| Rate for Payer: Humana Medicaid |
$64.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$165.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.51
|
| Rate for Payer: Molina Healthcare Passport |
$64.23
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$77.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.87
|
|
|
FBR FOOT SUBCUTANIOUS(T
|
Facility
|
OP
|
$1,688.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
761T0989
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.44 |
| Max. Negotiated Rate |
$1,620.48 |
| Rate for Payer: Aetna Commercial |
$1,299.76
|
| Rate for Payer: Anthem Medicaid |
$580.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,316.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$844.00
|
| Rate for Payer: Cash Price |
$844.00
|
| Rate for Payer: Cigna Commercial |
$1,401.04
|
| Rate for Payer: First Health Commercial |
$1,603.60
|
| Rate for Payer: Humana Commercial |
$1,434.80
|
| Rate for Payer: Humana KY Medicaid |
$580.50
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$586.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,384.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,245.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$592.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,485.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,266.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$337.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$523.28
|
| Rate for Payer: PHCS Commercial |
$1,620.48
|
| Rate for Payer: United Healthcare All Payer |
$1,485.44
|
|
|
FBR FOOT SUBCUTANIOUS(T
|
Facility
|
IP
|
$1,688.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
761T0989
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.44 |
| Max. Negotiated Rate |
$1,620.48 |
| Rate for Payer: Aetna Commercial |
$1,299.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,316.64
|
| Rate for Payer: Cash Price |
$844.00
|
| Rate for Payer: Cigna Commercial |
$1,401.04
|
| Rate for Payer: First Health Commercial |
$1,603.60
|
| Rate for Payer: Humana Commercial |
$1,434.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,384.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,245.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$506.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,485.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,266.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$337.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$523.28
|
| Rate for Payer: PHCS Commercial |
$1,620.48
|
| Rate for Payer: United Healthcare All Payer |
$1,485.44
|
|
|
FBR MUSCLE OR TENDON SIMPLE
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 20520
|
| Hospital Charge Code |
45000087
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
FBR MUSCLE OR TENDON SIMPLE
|
Professional
|
Both
|
$3,085.00
|
|
|
Service Code
|
HCPCS 20520
|
| Hospital Charge Code |
76100334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$3,085.00 |
| Rate for Payer: Aetna Commercial |
$204.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$90.29
|
| Rate for Payer: Anthem Medicaid |
$64.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,085.00
|
| Rate for Payer: Cash Price |
$1,542.50
|
| Rate for Payer: Cash Price |
$1,542.50
|
| Rate for Payer: Cigna Commercial |
$230.30
|
| Rate for Payer: Healthspan PPO |
$240.28
|
| Rate for Payer: Humana Medicaid |
$64.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.57
|
| Rate for Payer: Molina Healthcare Passport |
$64.28
|
| Rate for Payer: Multiplan PHCS |
$1,851.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,159.50
|
| Rate for Payer: UHCCP Medicaid |
$94.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.92
|
|
|
FBR MUSCLE OR TENDON SIMPLE
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 20520
|
| Hospital Charge Code |
45000087
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| 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 |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
FBR MUSCLE OR TENDON SIMPLE
|
Facility
|
IP
|
$3,085.00
|
|
|
Service Code
|
HCPCS 20520
|
| Hospital Charge Code |
76100333
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$401.05 |
| Max. Negotiated Rate |
$2,961.60 |
| Rate for Payer: Aetna Commercial |
$2,375.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.30
|
| Rate for Payer: Cash Price |
$1,542.50
|
| Rate for Payer: Cigna Commercial |
$2,560.55
|
| Rate for Payer: First Health Commercial |
$2,930.75
|
| Rate for Payer: Humana Commercial |
$2,622.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$925.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$617.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.35
|
| Rate for Payer: PHCS Commercial |
$2,961.60
|
| Rate for Payer: United Healthcare All Payer |
$2,714.80
|
|
|
FBR MUSCLE OR TENDON SIMPLE
|
Facility
|
OP
|
$3,085.00
|
|
|
Service Code
|
HCPCS 20520
|
| Hospital Charge Code |
76100334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$401.05 |
| Max. Negotiated Rate |
$2,961.60 |
| Rate for Payer: Aetna Commercial |
$2,375.45
|
| Rate for Payer: Anthem Medicaid |
$1,060.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.30
|
| 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 |
$1,542.50
|
| Rate for Payer: Cash Price |
$1,542.50
|
| Rate for Payer: Cigna Commercial |
$2,560.55
|
| Rate for Payer: First Health Commercial |
$2,930.75
|
| Rate for Payer: Humana Commercial |
$2,622.25
|
| Rate for Payer: Humana KY Medicaid |
$1,060.93
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,071.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,082.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$617.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.35
|
| Rate for Payer: PHCS Commercial |
$2,961.60
|
| Rate for Payer: United Healthcare All Payer |
$2,714.80
|
|
|
FBR MUSCLE OR TENDON SIMPLE
|
Facility
|
OP
|
$3,085.00
|
|
|
Service Code
|
HCPCS 20520
|
| Hospital Charge Code |
76100333
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$401.05 |
| Max. Negotiated Rate |
$2,961.60 |
| Rate for Payer: Aetna Commercial |
$2,375.45
|
| Rate for Payer: Anthem Medicaid |
$1,060.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.30
|
| 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 |
$1,542.50
|
| Rate for Payer: Cash Price |
$1,542.50
|
| Rate for Payer: Cigna Commercial |
$2,560.55
|
| Rate for Payer: First Health Commercial |
$2,930.75
|
| Rate for Payer: Humana Commercial |
$2,622.25
|
| Rate for Payer: Humana KY Medicaid |
$1,060.93
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,071.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,082.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$617.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.35
|
| Rate for Payer: PHCS Commercial |
$2,961.60
|
| Rate for Payer: United Healthcare All Payer |
$2,714.80
|
|
