|
FBR SKIN W/INCISION SIMPLE(T
|
Facility
|
IP
|
$569.00
|
|
|
Service Code
|
HCPCS 10120
|
| Hospital Charge Code |
761T0012
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$170.70 |
| Max. Negotiated Rate |
$546.24 |
| Rate for Payer: Aetna Commercial |
$438.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$443.82
|
| Rate for Payer: Cash Price |
$284.50
|
| Rate for Payer: Cigna Commercial |
$472.27
|
| Rate for Payer: First Health Commercial |
$540.55
|
| Rate for Payer: Humana Commercial |
$483.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$466.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$419.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$500.72
|
| Rate for Payer: Ohio Health Group HMO |
$426.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$392.61
|
| Rate for Payer: PHCS Commercial |
$546.24
|
| Rate for Payer: United Healthcare All Payer |
$500.72
|
|
|
FBR SKIN W/INCISION SIMPLE(T
|
Facility
|
OP
|
$569.00
|
|
|
Service Code
|
HCPCS 10120
|
| Hospital Charge Code |
761T0012
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.68 |
| Max. Negotiated Rate |
$546.24 |
| Rate for Payer: Aetna Commercial |
$438.13
|
| Rate for Payer: Anthem Medicaid |
$195.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$443.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$284.50
|
| Rate for Payer: Cash Price |
$284.50
|
| Rate for Payer: Cigna Commercial |
$472.27
|
| Rate for Payer: First Health Commercial |
$540.55
|
| Rate for Payer: Humana Commercial |
$483.65
|
| Rate for Payer: Humana KY Medicaid |
$195.68
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$197.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$466.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$419.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$500.72
|
| Rate for Payer: Ohio Health Group HMO |
$426.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$392.61
|
| Rate for Payer: PHCS Commercial |
$546.24
|
| Rate for Payer: United Healthcare All Payer |
$500.72
|
|
|
FBR SKIN W SUBCU COMPLICATED
|
Facility
|
OP
|
$2,584.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
76100013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$888.64 |
| Max. Negotiated Rate |
$2,480.64 |
| Rate for Payer: Aetna Commercial |
$1,989.68
|
| Rate for Payer: Anthem Medicaid |
$888.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,015.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cigna Commercial |
$2,144.72
|
| Rate for Payer: First Health Commercial |
$2,454.80
|
| Rate for Payer: Humana Commercial |
$2,196.40
|
| Rate for Payer: Humana KY Medicaid |
$888.64
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$897.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,118.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,906.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$906.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,273.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,938.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,067.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,248.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,782.96
|
| Rate for Payer: PHCS Commercial |
$2,480.64
|
| Rate for Payer: United Healthcare All Payer |
$2,273.92
|
|
|
FBR SKIN W SUBCU COMPLICATED
|
Professional
|
Both
|
$2,584.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
76100013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.61 |
| Max. Negotiated Rate |
$1,550.40 |
| Rate for Payer: Aetna Commercial |
$269.85
|
| Rate for Payer: Ambetter Exchange |
$172.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.61
|
| Rate for Payer: Anthem Medicaid |
$107.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$172.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$172.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$207.56
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cigna Commercial |
$356.32
|
| Rate for Payer: Healthspan PPO |
$291.94
|
| Rate for Payer: Humana Medicaid |
$107.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$172.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.34
|
| Rate for Payer: Molina Healthcare Passport |
$107.20
|
| Rate for Payer: Multiplan PHCS |
$1,550.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.86
|
| Rate for Payer: UHCCP Medicaid |
$98.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$172.97
|
|
|
FBR SKIN W SUBCU COMPLICATED
|
Facility
|
IP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
45000023
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$655.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
FBR SKIN W SUBCU COMPLICATED
|
Facility
|
OP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
45000023
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$751.08 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem Medicaid |
$751.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Humana KY Medicaid |
$751.08
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$766.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
FBR SKIN W SUBCU COMPLICATED
|
Facility
|
IP
|
$2,584.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
76100013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$775.20 |
| Max. Negotiated Rate |
$2,480.64 |
| Rate for Payer: Aetna Commercial |
$1,989.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,015.52
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cigna Commercial |
$2,144.72
|
| Rate for Payer: First Health Commercial |
$2,454.80
|
| Rate for Payer: Humana Commercial |
$2,196.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,118.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,906.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$775.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,273.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,938.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,067.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,248.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,782.96
|
| Rate for Payer: PHCS Commercial |
$2,480.64
|
| Rate for Payer: United Healthcare All Payer |
$2,273.92
|
|
|
FBR SKIN W SUBCU COMPLICATED(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
761P0013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.61 |
| Max. Negotiated Rate |
$356.32 |
| Rate for Payer: Aetna Commercial |
$269.85
|
| Rate for Payer: Ambetter Exchange |
$172.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.61
|
| Rate for Payer: Anthem Medicaid |
$107.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$172.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$172.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$207.56
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$356.32
|
| Rate for Payer: Healthspan PPO |
$291.94
|
| Rate for Payer: Humana Medicaid |
$107.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$172.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.34
|
| Rate for Payer: Molina Healthcare Passport |
$107.20
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.86
|
| Rate for Payer: UHCCP Medicaid |
$98.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$172.97
|
|
|
FBR SKIN W SUBCU COMPLICATED(T
|
Facility
|
OP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
761T0013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$751.08 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem Medicaid |
$751.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Humana KY Medicaid |
$751.08
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$766.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
FBR SKIN W SUBCU COMPLICATED(T
|
Facility
|
IP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
761T0013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$655.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
FECAL LACTOFERRIN QUAL
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 83630
|
| Hospital Charge Code |
30000438
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem Medicaid |
$19.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$19.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$175.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$27.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.70
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Humana KY Medicaid |
$19.70
|
| Rate for Payer: Humana Medicare Advantage |
$19.70
|
| Rate for Payer: Kentucky WC Medicaid |
$19.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$174.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$189.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.42
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
FECAL LACTOFERRIN QUAL
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 83630
|
| Hospital Charge Code |
30000438
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$65.40 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$175.05
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$174.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$189.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.42
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
FECAL MICROBIOTA PREP INSTIL
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
HCPCS G0455
|
| Hospital Charge Code |
30001776
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$129.03 |
| Max. Negotiated Rate |
$1,179.36 |
| Rate for Payer: Aetna Commercial |
$143.99
|
| Rate for Payer: Anthem Medicaid |
$842.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$842.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$150.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,179.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$842.40
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$155.21
|
| Rate for Payer: First Health Commercial |
$177.65
|
| Rate for Payer: Humana Commercial |
$158.95
|
| Rate for Payer: Humana KY Medicaid |
$842.40
|
| Rate for Payer: Humana Medicare Advantage |
$842.40
|
| Rate for Payer: Kentucky WC Medicaid |
$850.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$859.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.56
|
| Rate for Payer: Ohio Health Group HMO |
$140.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.03
|
| Rate for Payer: PHCS Commercial |
$179.52
|
| Rate for Payer: United Healthcare All Payer |
$164.56
|
|
|
FECAL MICROBIOTA PREP INSTIL
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
HCPCS G0455
|
| Hospital Charge Code |
30001776
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$179.52 |
| Rate for Payer: Aetna Commercial |
$143.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$150.16
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$155.21
|
| Rate for Payer: First Health Commercial |
$177.65
|
| Rate for Payer: Humana Commercial |
$158.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.56
|
| Rate for Payer: Ohio Health Group HMO |
$140.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.03
|
| Rate for Payer: PHCS Commercial |
$179.52
|
| Rate for Payer: United Healthcare All Payer |
$164.56
|
|
|
FEC OCCULT BL IMMUN 1-3 SIM
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
30000254
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.80 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.12
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.14
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
FEC OCCULT BL IMMUN 1-3 SIM
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
30000254
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.92 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem Medicaid |
$15.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.92
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Humana KY Medicaid |
$15.92
|
| Rate for Payer: Humana Medicare Advantage |
$15.92
|
| Rate for Payer: Kentucky WC Medicaid |
$16.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.14
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
FEC OCCULT BL IMMUN 1-3 SIM
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
HCPCS G0328
|
| Hospital Charge Code |
30000254
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem Medicaid |
$18.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.05
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Humana KY Medicaid |
$18.05
|
| Rate for Payer: Humana Medicare Advantage |
$18.05
|
| Rate for Payer: Kentucky WC Medicaid |
$18.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.14
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
FEC OCCULT BL IMMUN 1-3 SIM
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
HCPCS G0328
|
| Hospital Charge Code |
30000254
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.80 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.12
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.14
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
FELBATOL 600 MG TABLET
|
Facility
|
IP
|
$34.69
|
|
|
Service Code
|
NDC 37043101
|
| Hospital Charge Code |
25000664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$33.30 |
| Rate for Payer: Aetna Commercial |
$26.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.06
|
| Rate for Payer: Cash Price |
$17.34
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: First Health Commercial |
$32.96
|
| Rate for Payer: Humana Commercial |
$29.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.53
|
| Rate for Payer: Ohio Health Group HMO |
$26.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.94
|
| Rate for Payer: PHCS Commercial |
$33.30
|
| Rate for Payer: United Healthcare All Payer |
$30.53
|
|
|
FELBATOL 600 MG TABLET
|
Facility
|
OP
|
$34.69
|
|
|
Service Code
|
NDC 37043101
|
| Hospital Charge Code |
25000664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$33.30 |
| Rate for Payer: Aetna Commercial |
$26.71
|
| Rate for Payer: Anthem Medicaid |
$11.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.06
|
| Rate for Payer: Cash Price |
$17.34
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: First Health Commercial |
$32.96
|
| Rate for Payer: Humana Commercial |
$29.49
|
| Rate for Payer: Humana KY Medicaid |
$11.93
|
| Rate for Payer: Kentucky WC Medicaid |
$12.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.53
|
| Rate for Payer: Ohio Health Group HMO |
$26.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.94
|
| Rate for Payer: PHCS Commercial |
$33.30
|
| Rate for Payer: United Healthcare All Payer |
$30.53
|
|
|
FELDENE (PIROXICAM) 10MG/1CAP
|
Facility
|
IP
|
$4.81
|
|
|
Service Code
|
NDC 29033001201
|
| Hospital Charge Code |
25000666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.99
|
| Rate for Payer: First Health Commercial |
$4.57
|
| Rate for Payer: Humana Commercial |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.23
|
| Rate for Payer: Ohio Health Group HMO |
$3.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.32
|
| Rate for Payer: PHCS Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$4.23
|
|
|
FELDENE (PIROXICAM) 10MG/1CAP
|
Facility
|
OP
|
$4.81
|
|
|
Service Code
|
NDC 29033001201
|
| Hospital Charge Code |
25000666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.99
|
| Rate for Payer: First Health Commercial |
$4.57
|
| Rate for Payer: Humana Commercial |
$4.09
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.23
|
| Rate for Payer: Ohio Health Group HMO |
$3.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.32
|
| Rate for Payer: PHCS Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Payer |
$4.23
|
|
|
FEMARA(LETROZOLE)2.5 MG TAB
|
Facility
|
IP
|
$147.97
|
|
|
Service Code
|
NDC 78024915
|
| Hospital Charge Code |
25000667
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.39 |
| Max. Negotiated Rate |
$142.05 |
| Rate for Payer: Aetna Commercial |
$113.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.42
|
| Rate for Payer: Cash Price |
$73.98
|
| Rate for Payer: Cigna Commercial |
$122.82
|
| Rate for Payer: First Health Commercial |
$140.57
|
| Rate for Payer: Humana Commercial |
$125.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.21
|
| Rate for Payer: Ohio Health Group HMO |
$110.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$128.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.10
|
| Rate for Payer: PHCS Commercial |
$142.05
|
| Rate for Payer: United Healthcare All Payer |
$130.21
|
|
|
FEMARA(LETROZOLE)2.5 MG TAB
|
Facility
|
OP
|
$147.97
|
|
|
Service Code
|
NDC 78024915
|
| Hospital Charge Code |
25000667
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.39 |
| Max. Negotiated Rate |
$142.05 |
| Rate for Payer: Aetna Commercial |
$113.94
|
| Rate for Payer: Anthem Medicaid |
$50.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.42
|
| Rate for Payer: Cash Price |
$73.98
|
| Rate for Payer: Cigna Commercial |
$122.82
|
| Rate for Payer: First Health Commercial |
$140.57
|
| Rate for Payer: Humana Commercial |
$125.77
|
| Rate for Payer: Humana KY Medicaid |
$50.89
|
| Rate for Payer: Kentucky WC Medicaid |
$51.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.21
|
| Rate for Payer: Ohio Health Group HMO |
$110.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$128.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.10
|
| Rate for Payer: PHCS Commercial |
$142.05
|
| Rate for Payer: United Healthcare All Payer |
$130.21
|
|
|
FEM BLUSHINGS POLY RS OSS
|
Facility
|
OP
|
$4,313.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.01 |
| Max. Negotiated Rate |
$4,140.84 |
| Rate for Payer: Aetna Commercial |
$3,321.30
|
| Rate for Payer: Anthem Medicaid |
$1,483.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,364.44
|
| Rate for Payer: Cash Price |
$2,156.69
|
| Rate for Payer: Cigna Commercial |
$3,580.11
|
| Rate for Payer: First Health Commercial |
$4,097.71
|
| Rate for Payer: Humana Commercial |
$3,666.37
|
| Rate for Payer: Humana KY Medicaid |
$1,483.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,498.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,536.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,183.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,795.77
|
| Rate for Payer: Ohio Health Group HMO |
$3,235.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,450.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,752.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,976.23
|
| Rate for Payer: PHCS Commercial |
$4,140.84
|
| Rate for Payer: United Healthcare All Payer |
$3,795.77
|
|
