|
FULL THICKNESS GRAFT - CLOSU(T
|
Facility
|
OP
|
$4,085.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
761T0184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$531.13 |
| Max. Negotiated Rate |
$3,922.22 |
| Rate for Payer: Aetna Commercial |
$3,145.95
|
| Rate for Payer: Anthem Medicaid |
$1,405.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,186.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cigna Commercial |
$3,391.09
|
| Rate for Payer: First Health Commercial |
$3,881.37
|
| Rate for Payer: Humana Commercial |
$3,472.80
|
| Rate for Payer: Humana KY Medicaid |
$1,405.06
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,419.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,350.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,015.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,433.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,595.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,064.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,266.55
|
| Rate for Payer: PHCS Commercial |
$3,922.22
|
| Rate for Payer: United Healthcare All Payer |
$3,595.37
|
|
|
FULL THICKNESS GRAFT(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
761P0188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.52 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,207.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$426.52
|
| Rate for Payer: Anthem Medicaid |
$504.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,128.38
|
| Rate for Payer: Healthspan PPO |
$1,097.43
|
| Rate for Payer: Humana Medicaid |
$504.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,080.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$514.76
|
| Rate for Payer: Molina Healthcare Passport |
$504.67
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$447.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$509.72
|
|
|
FULL THICKNESS GRAFT(T
|
Facility
|
IP
|
$4,380.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
761T0188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$569.44 |
| Max. Negotiated Rate |
$4,205.12 |
| Rate for Payer: Aetna Commercial |
$3,372.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,416.66
|
| Rate for Payer: Cash Price |
$2,190.16
|
| Rate for Payer: Cigna Commercial |
$3,635.67
|
| Rate for Payer: First Health Commercial |
$4,161.31
|
| Rate for Payer: Humana Commercial |
$3,723.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,591.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,232.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,314.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,854.69
|
| Rate for Payer: Ohio Health Group HMO |
$3,285.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$876.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,357.90
|
| Rate for Payer: PHCS Commercial |
$4,205.12
|
| Rate for Payer: United Healthcare All Payer |
$3,854.69
|
|
|
FULL THICKNESS GRAFT(T
|
Facility
|
OP
|
$4,380.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
761T0188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$569.44 |
| Max. Negotiated Rate |
$4,205.12 |
| Rate for Payer: Aetna Commercial |
$3,372.85
|
| Rate for Payer: Anthem Medicaid |
$1,506.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,416.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,190.16
|
| Rate for Payer: Cash Price |
$2,190.16
|
| Rate for Payer: Cigna Commercial |
$3,635.67
|
| Rate for Payer: First Health Commercial |
$4,161.31
|
| Rate for Payer: Humana Commercial |
$3,723.28
|
| Rate for Payer: Humana KY Medicaid |
$1,506.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,521.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,591.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,232.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,536.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,854.69
|
| Rate for Payer: Ohio Health Group HMO |
$3,285.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$876.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,357.90
|
| Rate for Payer: PHCS Commercial |
$4,205.12
|
| Rate for Payer: United Healthcare All Payer |
$3,854.69
|
|
|
FULPHILA 6MG/0.6ML SYR
|
Facility
|
OP
|
$11,376.88
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
25002733
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.54 |
| Max. Negotiated Rate |
$10,921.80 |
| Rate for Payer: Aetna Commercial |
$8,760.20
|
| Rate for Payer: Anthem Medicaid |
$3,912.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$122.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,873.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$171.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.43
|
| Rate for Payer: Cash Price |
$5,688.44
|
| Rate for Payer: Cash Price |
$5,688.44
|
| Rate for Payer: Cigna Commercial |
$9,442.81
|
| Rate for Payer: First Health Commercial |
$10,808.04
|
| Rate for Payer: Humana Commercial |
$9,670.35
|
| Rate for Payer: Humana KY Medicaid |
$3,912.51
|
| Rate for Payer: Humana Medicare Advantage |
$122.54
|
| Rate for Payer: Kentucky WC Medicaid |
$3,952.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,329.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,396.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,991.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,011.65
|
| Rate for Payer: Ohio Health Group HMO |
$8,532.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,275.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,478.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,526.83
|
| Rate for Payer: PHCS Commercial |
$10,921.80
|
| Rate for Payer: United Healthcare All Payer |
$10,011.65
|
|
|
FULPHILA 6MG/0.6ML SYR
|
Facility
|
IP
|
$11,376.88
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
25002733
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,478.99 |
| Max. Negotiated Rate |
$10,921.80 |
| Rate for Payer: Aetna Commercial |
$8,760.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,873.97
|
| Rate for Payer: Cash Price |
$5,688.44
|
| Rate for Payer: Cigna Commercial |
$9,442.81
|
| Rate for Payer: First Health Commercial |
$10,808.04
|
| Rate for Payer: Humana Commercial |
$9,670.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,329.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,396.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,413.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,011.65
|
| Rate for Payer: Ohio Health Group HMO |
$8,532.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,275.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,478.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,526.83
|
| Rate for Payer: PHCS Commercial |
$10,921.80
|
| Rate for Payer: United Healthcare All Payer |
$10,011.65
|
|
|
FUNCTIONAL CAPACITY 15 MIN 1
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
43000030
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem Medicaid |
$38.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Humana KY Medicaid |
$38.86
|
| Rate for Payer: Kentucky WC Medicaid |
$39.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.03
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
FUNCTIONAL CAPACITY 15 MIN 1
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
43000030
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.03
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
FUNGIZONE (AMPHOTERI 50MG/10ML
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
25001858
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.52 |
| Max. Negotiated Rate |
$195.84 |
| Rate for Payer: Aetna Commercial |
$157.08
|
| Rate for Payer: Anthem Medicaid |
$70.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.12
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$169.32
|
| Rate for Payer: First Health Commercial |
$193.80
|
| Rate for Payer: Humana Commercial |
$173.40
|
| Rate for Payer: Humana KY Medicaid |
$70.16
|
| Rate for Payer: Kentucky WC Medicaid |
$70.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$167.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$179.52
|
| Rate for Payer: Ohio Health Group HMO |
$153.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.24
|
| Rate for Payer: PHCS Commercial |
$195.84
|
| Rate for Payer: United Healthcare All Payer |
$179.52
|
|
|
FUNGIZONE (AMPHOTERI 50MG/10ML
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
25001858
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.52 |
| Max. Negotiated Rate |
$195.84 |
| Rate for Payer: Aetna Commercial |
$157.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.12
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$169.32
|
| Rate for Payer: First Health Commercial |
$193.80
|
| Rate for Payer: Humana Commercial |
$173.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$167.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$179.52
|
| Rate for Payer: Ohio Health Group HMO |
$153.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.24
|
| Rate for Payer: PHCS Commercial |
$195.84
|
| Rate for Payer: United Healthcare All Payer |
$179.52
|
|
|
FUNGUS CULT - BLD W/ID ISOLATE
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 87103
|
| Hospital Charge Code |
30001275
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.40
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.85
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
FUNGUS CULT - BLD W/ID ISOLATE
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 87103
|
| Hospital Charge Code |
30001275
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem Medicaid |
$20.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Humana KY Medicaid |
$20.46
|
| Rate for Payer: Humana Medicare Advantage |
$20.46
|
| Rate for Payer: Kentucky WC Medicaid |
$20.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.85
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
FUNGUS PRESUMPTIVE IDENT
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS 87102
|
| Hospital Charge Code |
30001274
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem Medicaid |
$8.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.41
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Humana KY Medicaid |
$8.41
|
| Rate for Payer: Humana Medicare Advantage |
$8.41
|
| Rate for Payer: Kentucky WC Medicaid |
$8.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
FUNGUS PRESUMPTIVE IDENT
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS 87102
|
| Hospital Charge Code |
30001274
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
FUNGUS -SKINHAIRNAILS-W/ID ISO
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS 87101
|
| Hospital Charge Code |
30001273
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Aetna Commercial |
$77.77
|
| Rate for Payer: Anthem Medicaid |
$7.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.71
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$83.83
|
| Rate for Payer: First Health Commercial |
$95.95
|
| Rate for Payer: Humana Commercial |
$85.85
|
| Rate for Payer: Humana KY Medicaid |
$7.71
|
| Rate for Payer: Humana Medicare Advantage |
$7.71
|
| Rate for Payer: Kentucky WC Medicaid |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.88
|
| Rate for Payer: Ohio Health Group HMO |
$75.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.31
|
| Rate for Payer: PHCS Commercial |
$96.96
|
| Rate for Payer: United Healthcare All Payer |
$88.88
|
|
|
FUNGUS -SKINHAIRNAILS-W/ID ISO
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS 87101
|
| Hospital Charge Code |
30001273
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.13 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Aetna Commercial |
$77.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.10
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$83.83
|
| Rate for Payer: First Health Commercial |
$95.95
|
| Rate for Payer: Humana Commercial |
$85.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.88
|
| Rate for Payer: Ohio Health Group HMO |
$75.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.31
|
| Rate for Payer: PHCS Commercial |
$96.96
|
| Rate for Payer: United Healthcare All Payer |
$88.88
|
|
|
FUNGUS SMEAR ONLY W/INTERP.
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001325
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.16
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.05
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
FUNGUS SMEAR ONLY W/INTERP.
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001325
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Humana Medicare Advantage |
$4.27
|
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$4.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$4.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.05
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
FUROSEMIDE 20mg (100mg SDV)
|
Facility
|
OP
|
$77.78
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
25002201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$74.67 |
| Rate for Payer: Aetna Commercial |
$59.89
|
| Rate for Payer: Anthem Medicaid |
$26.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.67
|
| Rate for Payer: Cash Price |
$38.89
|
| Rate for Payer: Cigna Commercial |
$64.56
|
| Rate for Payer: First Health Commercial |
$73.89
|
| Rate for Payer: Humana Commercial |
$66.11
|
| Rate for Payer: Humana KY Medicaid |
$26.75
|
| Rate for Payer: Kentucky WC Medicaid |
$27.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.45
|
| Rate for Payer: Ohio Health Group HMO |
$58.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.11
|
| Rate for Payer: PHCS Commercial |
$74.67
|
| Rate for Payer: United Healthcare All Payer |
$68.45
|
|
|
FUROSEMIDE 20mg (100mg SDV)
|
Facility
|
IP
|
$77.78
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
25002201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$74.67 |
| Rate for Payer: Aetna Commercial |
$59.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.67
|
| Rate for Payer: Cash Price |
$38.89
|
| Rate for Payer: Cigna Commercial |
$64.56
|
| Rate for Payer: First Health Commercial |
$73.89
|
| Rate for Payer: Humana Commercial |
$66.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.45
|
| Rate for Payer: Ohio Health Group HMO |
$58.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.11
|
| Rate for Payer: PHCS Commercial |
$74.67
|
| Rate for Payer: United Healthcare All Payer |
$68.45
|
|
|
FUROSEMIDE 20mg (20mg SDV)
|
Facility
|
IP
|
$78.10
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
25002200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$74.98 |
| Rate for Payer: Aetna Commercial |
$60.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.92
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Cigna Commercial |
$64.82
|
| Rate for Payer: First Health Commercial |
$74.20
|
| Rate for Payer: Humana Commercial |
$66.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.73
|
| Rate for Payer: Ohio Health Group HMO |
$58.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.21
|
| Rate for Payer: PHCS Commercial |
$74.98
|
| Rate for Payer: United Healthcare All Payer |
$68.73
|
|
|
FUROSEMIDE 20mg (20mg SDV)
|
Facility
|
OP
|
$78.10
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
25002200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$74.98 |
| Rate for Payer: Aetna Commercial |
$60.14
|
| Rate for Payer: Anthem Medicaid |
$26.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.92
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Cigna Commercial |
$64.82
|
| Rate for Payer: First Health Commercial |
$74.20
|
| Rate for Payer: Humana Commercial |
$66.38
|
| Rate for Payer: Humana KY Medicaid |
$26.86
|
| Rate for Payer: Kentucky WC Medicaid |
$27.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.73
|
| Rate for Payer: Ohio Health Group HMO |
$58.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.21
|
| Rate for Payer: PHCS Commercial |
$74.98
|
| Rate for Payer: United Healthcare All Payer |
$68.73
|
|
|
FUROSEMIDE 20mg (40mg SDV)
|
Facility
|
OP
|
$78.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
25002199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$75.74 |
| Rate for Payer: Aetna Commercial |
$60.75
|
| Rate for Payer: Anthem Medicaid |
$27.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.54
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Cigna Commercial |
$65.49
|
| Rate for Payer: First Health Commercial |
$74.96
|
| Rate for Payer: Humana Commercial |
$67.06
|
| Rate for Payer: Humana KY Medicaid |
$27.13
|
| Rate for Payer: Kentucky WC Medicaid |
$27.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.43
|
| Rate for Payer: Ohio Health Group HMO |
$59.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.46
|
| Rate for Payer: PHCS Commercial |
$75.74
|
| Rate for Payer: United Healthcare All Payer |
$69.43
|
|
|
FUROSEMIDE 20mg (40mg SDV)
|
Facility
|
IP
|
$78.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
25002199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$75.74 |
| Rate for Payer: Aetna Commercial |
$60.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.54
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Cigna Commercial |
$65.49
|
| Rate for Payer: First Health Commercial |
$74.96
|
| Rate for Payer: Humana Commercial |
$67.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.43
|
| Rate for Payer: Ohio Health Group HMO |
$59.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.46
|
| Rate for Payer: PHCS Commercial |
$75.74
|
| Rate for Payer: United Healthcare All Payer |
$69.43
|
|
|
FUROSEMIDE 20MG SDV
|
Facility
|
IP
|
$73.48
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
636T0039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$70.54 |
| Rate for Payer: Aetna Commercial |
$56.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.31
|
| Rate for Payer: Cash Price |
$36.74
|
| Rate for Payer: Cigna Commercial |
$60.99
|
| Rate for Payer: First Health Commercial |
$69.81
|
| Rate for Payer: Humana Commercial |
$62.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.66
|
| Rate for Payer: Ohio Health Group HMO |
$55.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.78
|
| Rate for Payer: PHCS Commercial |
$70.54
|
| Rate for Payer: United Healthcare All Payer |
$64.66
|
|
