 |
Provider Contract Analysis Detail |
 |
|
| By Group Code |
Report Date: 11/04/2003 |
| By PPO Contract |
Report Period: 10/01/2003 - 10/31/2003 Paid |
| | |
| Coverage Analysis |
Description |
Type |
Count |
Charge |
Paid |
Avg Paid |
Total Disc |
Avg Disc |
| Group: 99999 |
| PPO Cnt: |
| Ben Type: CS |
| 03 |
HOSPITAL MISC -OUTPATIENT |
Non-PPO |
2 |
$2,415.21 |
$1,492.46 |
$746.23 |
$673.92 |
$336.96 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$2,415.21 |
$1,492.46 |
$746.23 |
$673.92 |
$336.96 |
| |
| 05 |
SURGERY - INPATIENT |
Non-PPO |
1 |
$3,000.00 |
$1,860.60 |
$1,860.60 |
$300.00 |
$300.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$3,000.00 |
$1,860.60 |
$1,860.60 |
$300.00 |
$300.00 |
| |
| 06 |
ANESTHESIA - OUTPATIENT |
Non-PPO |
2 |
$1,275.00 |
$628.25 |
$314.13 |
$127.50 |
$63.75 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$1,275.00 |
$628.25 |
$314.13 |
$127.50 |
$63.75 |
| |
| 07 |
ANESTHESIA - INPATIENT |
Non-PPO |
2 |
$2,080.00 |
$1,211.00 |
$605.50 |
$350.00 |
$175.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$2,080.00 |
$1,211.00 |
$605.50 |
$350.00 |
$175.00 |
| |
| 08 |
PHYSICIAN VISIT - INPTNT |
Non-PPO |
8 |
$1,099.00 |
$402.66 |
$50.33 |
$128.78 |
$16.10 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
8 |
$1,099.00 |
$402.66 |
$50.33 |
$128.78 |
$16.10 |
| |
| 09 |
PHYSICIAN VISIT - OUTPTNT |
Non-PPO |
29 |
$4,016.68 |
$1,041.89 |
$35.93 |
$593.58 |
$20.47 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
29 |
$4,016.68 |
$1,041.89 |
$35.93 |
$593.58 |
$20.47 |
| |
| 12 |
PSYCHIATRIC OP SERVICES |
Non-PPO |
1 |
$84.00 |
$26.50 |
$26.50 |
$31.00 |
$31.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$84.00 |
$26.50 |
$26.50 |
$31.00 |
$31.00 |
| |
| 14 |
SUBS ABUSE ROOM & BOARD |
Non-PPO |
10 |
$11,950.00 |
$11,352.50 |
$1,135.25 |
$597.50 |
$59.75 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
10 |
$11,950.00 |
$11,352.50 |
$1,135.25 |
$597.50 |
$59.75 |
| |
| 16 |
SUBS ABUSE OP SERVICES |
Non-PPO |
5 |
$2,875.00 |
$2,731.25 |
$546.25 |
$143.75 |
$28.75 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$2,875.00 |
$2,731.25 |
$546.25 |
$143.75 |
$28.75 |
| |
| 18 |
DIAGNOSTICS - OUTPATIENT |
Non-PPO |
32 |
$4,212.75 |
$1,389.76 |
$43.43 |
$787.13 |
$24.60 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
32 |
$4,212.75 |
$1,389.76 |
$43.43 |
$787.13 |
$24.60 |
| |
| 20 |
ROUTINE CARE |
Non-PPO |
4 |
$144.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$144.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 22 |
THERAPY |
Non-PPO |
17 |
$1,243.50 |
$345.93 |
$20.35 |
$190.41 |
$11.20 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
17 |
$1,243.50 |
$345.93 |
$20.35 |
$190.41 |
$11.20 |
| |
| 25 |
OTHER MEDICAL SERVICES |
Non-PPO |
6 |
$642.07 |
$43.19 |
$7.20 |
$151.67 |
$25.28 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
6 |
$642.07 |
$43.19 |
$7.20 |
$151.67 |
$25.28 |
| |
| 42 |
CHIROPRACTIC CARE |
Non-PPO |
4 |
$170.00 |
$0.00 |
$0.00 |
$17.00 |
$4.25 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$170.00 |
$0.00 |
$0.00 |
$17.00 |
$4.25 |
| |
| 45 |
AMBULATORY SURGICAL CTR |
Non-PPO |
1 |
$4,752.06 |
$840.00 |
$840.00 |
$3,452.06 |
$3,452.06 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$4,752.06 |
$840.00 |
$840.00 |
$3,452.06 |
$3,452.06 |
| |
| 52 |
INJECTION(S) |
Non-PPO |
3 |
$2,003.40 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
3 |
$2,003.40 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 53 |
WELL CHILD CARE |
Non-PPO |
9 |
$315.00 |
$188.08 |
$20.90 |
$116.92 |
$12.99 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
9 |
$315.00 |
$188.08 |
$20.90 |
$116.92 |
$12.99 |
| |
| 60 |
PODIATRIC CARE |
Non-PPO |
1 |
$125.00 |
$0.00 |
$0.00 |
$25.00 |
$25.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$125.00 |
$0.00 |
$0.00 |
$25.00 |
$25.00 |
| Total Ben Type: CS |
| |
|
Non-PPO |
137 |
$42,402.67 |
$23,554.07 |
$171.93 |
$7,686.22 |
$56.10 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
137 |
$42,402.67 |
$23,554.07 |
$171.93 |
$7,686.22 |
$56.10 |
| |
| Ben Type: D DENTAL |
| 27 |
INELIGIBLE EXPENSE |
Non-PPO |
52 |
$2,540.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
52 |
$2,540.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 30 |
DENTAL - PREVENTATIVE |
Non-PPO |
1205 |
$50,906.90 |
$44,345.90 |
$36.80 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1205 |
$50,906.90 |
$44,345.90 |
$36.80 |
$0.00 |
$0.00 |
| |
| 31 |
DENTAL - BASIC |
Non-PPO |
986 |
$157,414.00 |
$54,702.64 |
$55.48 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
986 |
$157,414.00 |
$54,702.64 |
$55.48 |
$0.00 |
$0.00 |
| |
| 32 |
DENTAL - MAJOR |
Non-PPO |
2 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 33 |
DENTAL - ORTHODONTIA |
Non-PPO |
85 |
$15,002.10 |
$5,987.38 |
$70.44 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
85 |
$15,002.10 |
$5,987.38 |
$70.44 |
$0.00 |
$0.00 |
| |
| 41 |
ADJUSTMENT |
Non-PPO |
1 |
$85.00 |
$85.00 |
$85.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$85.00 |
$85.00 |
$85.00 |
$0.00 |
$0.00 |
| |
| 59 |
TMJ TREATMENT |
Non-PPO |
2 |
$1,130.00 |
$355.50 |
$177.75 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$1,130.00 |
$355.50 |
$177.75 |
$0.00 |
$0.00 |
| Total Ben Type: D |
| |
|
Non-PPO |
2333 |
$227,078.00 |
$105,476.42 |
$45.21 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2333 |
$227,078.00 |
$105,476.42 |
$45.21 |
$0.00 |
$0.00 |
| |
| Ben Type: M MEDICAL |
| 01 |
HOSPITAL ROOM & BOARD |
Non-PPO |
6 |
$29,936.00 |
$18,832.10 |
$3,138.68 |
$1,088.40 |
$181.40 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
6 |
$29,936.00 |
$18,832.10 |
$3,138.68 |
$1,088.40 |
$181.40 |
| |
| 02 |
HOSPITAL MISC - INPATIENT |
Non-PPO |
4 |
$135,143.09 |
$90,185.61 |
$22,546.40 |
$4,662.09 |
$1,165.52 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$135,143.09 |
$90,185.61 |
$22,546.40 |
$4,662.09 |
$1,165.52 |
| |
| 03 |
HOSPITAL MISC -OUTPATIENT |
Non-PPO |
45 |
$38,723.12 |
$6,269.42 |
$139.32 |
$383.76 |
$8.53 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
45 |
$38,723.12 |
$6,269.42 |
$139.32 |
$383.76 |
$8.53 |
| |
| 04 |
SURGERY - OUTPATIENT |
Non-PPO |
18 |
$14,452.73 |
$5,625.38 |
$312.52 |
$3,000.00 |
$166.67 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
18 |
$14,452.73 |
$5,625.38 |
$312.52 |
$3,000.00 |
$166.67 |
| |
| 06 |
ANESTHESIA - OUTPATIENT |
Non-PPO |
8 |
$2,662.00 |
$798.15 |
$99.77 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
8 |
$2,662.00 |
$798.15 |
$99.77 |
$0.00 |
$0.00 |
| |
| 07 |
ANESTHESIA - INPATIENT |
Non-PPO |
2 |
$2,390.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$2,390.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 08 |
PHYSICIAN VISIT - INPTNT |
Non-PPO |
14 |
$1,434.00 |
$777.00 |
$55.50 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
14 |
$1,434.00 |
$777.00 |
$55.50 |
$0.00 |
$0.00 |
| |
| 09 |
PHYSICIAN VISIT - OUTPTNT |
Non-PPO |
239 |
$29,214.09 |
$3,133.72 |
$13.11 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
239 |
$29,214.09 |
$3,133.72 |
$13.11 |
$0.00 |
$0.00 |
| |
| 12 |
PSYCHIATRIC OP SERVICES |
Non-PPO |
14 |
$1,344.00 |
$532.00 |
$38.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
14 |
$1,344.00 |
$532.00 |
$38.00 |
$0.00 |
$0.00 |
| |
| 18 |
DIAGNOSTICS - OUTPATIENT |
Non-PPO |
100 |
$11,775.23 |
$5,943.18 |
$59.43 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
100 |
$11,775.23 |
$5,943.18 |
$59.43 |
$0.00 |
$0.00 |
| |
| 19 |
DIAGNOSTICS - INPATIENT |
Non-PPO |
8 |
$460.74 |
$3.27 |
$0.41 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
8 |
$460.74 |
$3.27 |
$0.41 |
$0.00 |
$0.00 |
| |
| 20 |
ROUTINE CARE |
Non-PPO |
16 |
$831.65 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
16 |
$831.65 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 21 |
PRESCRIPTION DRUGS |
Non-PPO |
3 |
$165.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
3 |
$165.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 22 |
THERAPY |
Non-PPO |
194 |
$11,959.00 |
$3,221.23 |
$16.60 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
194 |
$11,959.00 |
$3,221.23 |
$16.60 |
$0.00 |
$0.00 |
| |
| 24 |
HOME HEALTH CARE |
Non-PPO |
6 |
$840.00 |
$634.22 |
$105.70 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
6 |
$840.00 |
$634.22 |
$105.70 |
$0.00 |
$0.00 |
| |
| 25 |
OTHER MEDICAL SERVICES |
Non-PPO |
25 |
$6,100.10 |
$1,648.09 |
$65.92 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
25 |
$6,100.10 |
$1,648.09 |
$65.92 |
$0.00 |
$0.00 |
| |
| 27 |
INELIGIBLE EXPENSE |
Non-PPO |
56 |
$35,980.58 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
56 |
$35,980.58 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 41 |
ADJUSTMENT |
Non-PPO |
7 |
$203.37 |
$203.37 |
$29.05 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
7 |
$203.37 |
$203.37 |
$29.05 |
$0.00 |
$0.00 |
| |
| 42 |
CHIROPRACTIC CARE |
Non-PPO |
271 |
$9,439.00 |
$2,992.23 |
$11.04 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
271 |
$9,439.00 |
$2,992.23 |
$11.04 |
$0.00 |
$0.00 |
| |
| 45 |
AMBULATORY SURGICAL CTR |
Non-PPO |
9 |
$12,435.47 |
$6,555.40 |
$728.38 |
$1,584.07 |
$176.01 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
9 |
$12,435.47 |
$6,555.40 |
$728.38 |
$1,584.07 |
$176.01 |
| |
| 46 |
ASSISTANT SURGEON |
Non-PPO |
2 |
$2,187.50 |
$288.82 |
$144.41 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$2,187.50 |
$288.82 |
$144.41 |
$0.00 |
$0.00 |
| |
| 48 |
CASE MGT/AUDIT FEES |
Non-PPO |
3 |
$190.44 |
$90.44 |
$30.15 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
3 |
$190.44 |
$90.44 |
$30.15 |
$0.00 |
$0.00 |
| |
| 50 |
HOSPICE |
Non-PPO |
1 |
$514.52 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$514.52 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 52 |
INJECTION(S) |
Non-PPO |
19 |
$5,867.30 |
$436.61 |
$22.98 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
19 |
$5,867.30 |
$436.61 |
$22.98 |
$0.00 |
$0.00 |
| |
| 53 |
WELL CHILD CARE |
Non-PPO |
2 |
$140.00 |
$120.00 |
$60.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$140.00 |
$120.00 |
$60.00 |
$0.00 |
$0.00 |
| |
| 54 |
NEWBORN |
Non-PPO |
2 |
$3,749.88 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$3,749.88 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 60 |
PODIATRIC CARE |
Non-PPO |
4 |
$3,139.00 |
$3,058.00 |
$764.50 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$3,139.00 |
$3,058.00 |
$764.50 |
$0.00 |
$0.00 |
| |
| 63 |
AMBULANCE |
Non-PPO |
19 |
$7,240.38 |
$3,570.90 |
$187.94 |
$136.50 |
$7.18 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
19 |
$7,240.38 |
$3,570.90 |
$187.94 |
$136.50 |
$7.18 |
| Total Ben Type: M |
| |
|
Non-PPO |
1097 |
$368,518.19 |
$154,919.14 |
$141.22 |
$10,854.82 |
$9.90 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1097 |
$368,518.19 |
$154,919.14 |
$141.22 |
$10,854.82 |
$9.90 |
| |
| Ben Type: V VISION |
| 27 |
INELIGIBLE EXPENSE |
Non-PPO |
2 |
$70.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$70.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 34 |
VISION CARE |
Non-PPO |
242 |
$23,083.08 |
$10,323.32 |
$42.66 |
$115.86 |
$0.48 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
242 |
$23,083.08 |
$10,323.32 |
$42.66 |
$115.86 |
$0.48 |
| Total Ben Type: V |
| |
|
Non-PPO |
244 |
$23,153.08 |
$10,323.32 |
$42.31 |
$115.86 |
$0.47 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
244 |
$23,153.08 |
$10,323.32 |
$42.31 |
$115.86 |
$0.47 |
| |
| PPO Cnt: |
| Ben Type: M MEDICAL |
| |
|
PPO |
5 |
$4,905.95 |
$1,076.46 |
$215.29 |
$119.88 |
$23.98 |
| 01 |
HOSPITAL ROOM & BOARD |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$4,905.95 |
$1,076.46 |
$215.29 |
$119.88 |
$23.98 |
| |
| |
|
PPO |
5 |
$62,710.91 |
$16,059.40 |
$3,211.88 |
$1,744.76 |
$348.95 |
| 02 |
HOSPITAL MISC - INPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$62,710.91 |
$16,059.40 |
$3,211.88 |
$1,744.76 |
$348.95 |
| |
| |
|
PPO |
96 |
$61,584.36 |
$21,812.58 |
$227.21 |
$3,796.82 |
$39.55 |
| 03 |
HOSPITAL MISC -OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
96 |
$61,584.36 |
$21,812.58 |
$227.21 |
$3,796.82 |
$39.55 |
| |
| |
|
PPO |
27 |
$11,544.00 |
$3,872.28 |
$143.42 |
$4,090.06 |
$151.48 |
| 04 |
SURGERY - OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
27 |
$11,544.00 |
$3,872.28 |
$143.42 |
$4,090.06 |
$151.48 |
| |
| |
|
PPO |
12 |
$11,516.50 |
$3,798.32 |
$316.53 |
$3,561.24 |
$296.77 |
| 05 |
SURGERY - INPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
12 |
$11,516.50 |
$3,798.32 |
$316.53 |
$3,561.24 |
$296.77 |
| |
| |
|
PPO |
3 |
$1,000.00 |
$565.82 |
$188.61 |
$371.31 |
$123.77 |
| 06 |
ANESTHESIA - OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
3 |
$1,000.00 |
$565.82 |
$188.61 |
$371.31 |
$123.77 |
| |
| |
|
PPO |
5 |
$3,906.00 |
$2,238.20 |
$447.64 |
$602.00 |
$120.40 |
| 07 |
ANESTHESIA - INPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$3,906.00 |
$2,238.20 |
$447.64 |
$602.00 |
$120.40 |
| |
| |
|
PPO |
7 |
$1,215.50 |
$620.08 |
$88.58 |
$233.26 |
$33.32 |
| 08 |
PHYSICIAN VISIT - INPTNT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
7 |
$1,215.50 |
$620.08 |
$88.58 |
$233.26 |
$33.32 |
| |
| |
|
PPO |
298 |
$28,402.83 |
$14,846.97 |
$49.82 |
$5,976.63 |
$20.06 |
| 09 |
PHYSICIAN VISIT - OUTPTNT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
298 |
$28,402.83 |
$14,846.97 |
$49.82 |
$5,976.63 |
$20.06 |
| |
| |
|
PPO |
16 |
$1,659.00 |
$736.47 |
$46.03 |
$172.53 |
$10.78 |
| 12 |
PSYCHIATRIC OP SERVICES |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
16 |
$1,659.00 |
$736.47 |
$46.03 |
$172.53 |
$10.78 |
| |
| |
|
PPO |
416 |
$33,961.10 |
$12,998.91 |
$31.25 |
$13,079.57 |
$31.44 |
| 18 |
DIAGNOSTICS - OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
416 |
$33,961.10 |
$12,998.91 |
$31.25 |
$13,079.57 |
$31.44 |
| |
| |
|
PPO |
28 |
$1,848.03 |
$724.35 |
$25.87 |
$860.40 |
$30.73 |
| 19 |
DIAGNOSTICS - INPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
28 |
$1,848.03 |
$724.35 |
$25.87 |
$860.40 |
$30.73 |
| |
| |
|
PPO |
66 |
$4,662.73 |
$2,608.06 |
$39.52 |
$787.20 |
$11.93 |
| 20 |
ROUTINE CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
66 |
$4,662.73 |
$2,608.06 |
$39.52 |
$787.20 |
$11.93 |
| |
| |
|
PPO |
32 |
$3,727.22 |
$1,711.14 |
$53.47 |
$253.56 |
$7.92 |
| 22 |
THERAPY |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
32 |
$3,727.22 |
$1,711.14 |
$53.47 |
$253.56 |
$7.92 |
| |
| |
|
PPO |
5 |
$950.40 |
$684.29 |
$136.86 |
$95.04 |
$19.01 |
| 23 |
SKLD NURSING FAC/CONV FAC |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$950.40 |
$684.29 |
$136.86 |
$95.04 |
$19.01 |
| |
| |
|
PPO |
21 |
$3,207.84 |
$1,227.04 |
$58.43 |
$927.30 |
$44.16 |
| 25 |
OTHER MEDICAL SERVICES |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
21 |
$3,207.84 |
$1,227.04 |
$58.43 |
$927.30 |
$44.16 |
| |
| |
|
PPO |
16 |
$2,006.10 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| 27 |
INELIGIBLE EXPENSE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
16 |
$2,006.10 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| |
|
PPO |
1 |
$500.00 |
$500.00 |
$500.00 |
$0.00 |
$0.00 |
| 37 |
PLAN EXCEPTION |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$500.00 |
$500.00 |
$500.00 |
$0.00 |
$0.00 |
| |
| |
|
PPO |
264 |
$8,436.00 |
$2,994.85 |
$11.34 |
$1,253.00 |
$4.75 |
| 42 |
CHIROPRACTIC CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
264 |
$8,436.00 |
$2,994.85 |
$11.34 |
$1,253.00 |
$4.75 |
| |
| |
|
PPO |
4 |
$11,486.50 |
$7,893.63 |
$1,973.41 |
$2,715.80 |
$678.95 |
| 45 |
AMBULATORY SURGICAL CTR |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$11,486.50 |
$7,893.63 |
$1,973.41 |
$2,715.80 |
$678.95 |
| |
| |
|
PPO |
1 |
$6,942.00 |
$6,247.80 |
$6,247.80 |
$694.20 |
$694.20 |
| 46 |
ASSISTANT SURGEON |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$6,942.00 |
$6,247.80 |
$6,247.80 |
$694.20 |
$694.20 |
| |
| |
|
PPO |
21 |
$30,259.00 |
$25,957.75 |
$1,236.08 |
$3,464.59 |
$164.98 |
| 49 |
CHEMO/RADIATION THERAPY |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
21 |
$30,259.00 |
$25,957.75 |
$1,236.08 |
$3,464.59 |
$164.98 |
| |
| |
|
PPO |
123 |
$8,914.12 |
$6,709.01 |
$54.54 |
$1,719.10 |
$13.98 |
| 52 |
INJECTION(S) |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
123 |
$8,914.12 |
$6,709.01 |
$54.54 |
$1,719.10 |
$13.98 |
| |
| |
|
PPO |
55 |
$2,762.00 |
$2,040.04 |
$37.09 |
$469.96 |
$8.54 |
| 53 |
WELL CHILD CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
55 |
$2,762.00 |
$2,040.04 |
$37.09 |
$469.96 |
$8.54 |
| |
| |
|
PPO |
4 |
$24,008.38 |
$20,223.96 |
$5,055.99 |
$2,400.88 |
$600.22 |
| 57 |
PRE-CERTIFICATION PENALTY |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$24,008.38 |
$20,223.96 |
$5,055.99 |
$2,400.88 |
$600.22 |
| |
| |
|
PPO |
2 |
$218.00 |
$100.81 |
$50.41 |
$103.70 |
$51.85 |
| 60 |
PODIATRIC CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$218.00 |
$100.81 |
$50.41 |
$103.70 |
$51.85 |
| |
| |
|
PPO |
2 |
$667.44 |
$667.44 |
$333.72 |
$0.00 |
$0.00 |
| 63 |
AMBULANCE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$667.44 |
$667.44 |
$333.72 |
$0.00 |
$0.00 |
| Total Ben Type: M |
| |
|
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
1535 |
$333,001.91 |
$158,915.66 |
$103.53 |
$49,492.79 |
$32.24 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1535 |
$333,001.91 |
$158,915.66 |
$103.53 |
$49,492.79 |
$32.24 |
| |
| PPO Cnt: |
| Ben Type: CS |
| 03 |
HOSPITAL MISC -OUTPATIENT |
Non-PPO |
11 |
$5,721.00 |
$2,198.97 |
$199.91 |
$1,558.15 |
$141.65 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
11 |
$5,721.00 |
$2,198.97 |
$199.91 |
$1,558.15 |
$141.65 |
| |
| 06 |
ANESTHESIA - OUTPATIENT |
Non-PPO |
1 |
$770.00 |
$129.07 |
$129.07 |
$341.60 |
$341.60 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$770.00 |
$129.07 |
$129.07 |
$341.60 |
$341.60 |
| |
| 08 |
PHYSICIAN VISIT - INPTNT |
Non-PPO |
5 |
$495.00 |
$284.90 |
$56.98 |
$88.02 |
$17.60 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$495.00 |
$284.90 |
$56.98 |
$88.02 |
$17.60 |
| |
| 09 |
PHYSICIAN VISIT - OUTPTNT |
Non-PPO |
23 |
$2,477.00 |
$396.78 |
$17.25 |
$561.21 |
$24.40 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
23 |
$2,477.00 |
$396.78 |
$17.25 |
$561.21 |
$24.40 |
| |
| 12 |
PSYCHIATRIC OP SERVICES |
Non-PPO |
2 |
$180.00 |
$71.25 |
$35.63 |
$37.52 |
$18.76 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$180.00 |
$71.25 |
$35.63 |
$37.52 |
$18.76 |
| |
| 18 |
DIAGNOSTICS - OUTPATIENT |
Non-PPO |
21 |
$1,757.00 |
$514.59 |
$24.50 |
$1,025.43 |
$48.83 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
21 |
$1,757.00 |
$514.59 |
$24.50 |
$1,025.43 |
$48.83 |
| |
| 22 |
THERAPY |
Non-PPO |
2 |
$176.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$176.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| 25 |
OTHER MEDICAL SERVICES |
Non-PPO |
5 |
$1,547.00 |
$535.98 |
$107.20 |
$710.02 |
$142.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
5 |
$1,547.00 |
$535.98 |
$107.20 |
$710.02 |
$142.00 |
| |
| 42 |
CHIROPRACTIC CARE |
Non-PPO |
28 |
$1,130.00 |
$48.18 |
$1.72 |
$132.76 |
$4.74 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
28 |
$1,130.00 |
$48.18 |
$1.72 |
$132.76 |
$4.74 |
| |
| 52 |
INJECTION(S) |
Non-PPO |
4 |
$2,118.40 |
$46.41 |
$11.60 |
$48.70 |
$12.18 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$2,118.40 |
$46.41 |
$11.60 |
$48.70 |
$12.18 |
| Total Ben Type: CS |
| |
|
Non-PPO |
102 |
$16,371.40 |
$4,226.13 |
$41.43 |
$4,503.41 |
$44.15 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
102 |
$16,371.40 |
$4,226.13 |
$41.43 |
$4,503.41 |
$44.15 |
| |
| PPO Cnt: |
| Ben Type: M MEDICAL |
| |
|
PPO |
10 |
$9,888.71 |
$6,670.68 |
$667.07 |
$1,871.85 |
$187.19 |
| 03 |
HOSPITAL MISC -OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
10 |
$9,888.71 |
$6,670.68 |
$667.07 |
$1,871.85 |
$187.19 |
| |
| |
|
PPO |
3 |
$852.00 |
$16.65 |
$5.55 |
$448.50 |
$149.50 |
| 04 |
SURGERY - OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
3 |
$852.00 |
$16.65 |
$5.55 |
$448.50 |
$149.50 |
| |
| |
|
PPO |
29 |
$3,184.00 |
$2,026.44 |
$69.88 |
$696.40 |
$24.01 |
| 09 |
PHYSICIAN VISIT - OUTPTNT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
29 |
$3,184.00 |
$2,026.44 |
$69.88 |
$696.40 |
$24.01 |
| |
| |
|
PPO |
45 |
$2,686.35 |
$1,493.80 |
$33.20 |
$1,004.30 |
$22.32 |
| 18 |
DIAGNOSTICS - OUTPATIENT |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
45 |
$2,686.35 |
$1,493.80 |
$33.20 |
$1,004.30 |
$22.32 |
| |
| |
|
PPO |
4 |
$319.00 |
$111.50 |
$27.88 |
$113.50 |
$28.38 |
| 20 |
ROUTINE CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$319.00 |
$111.50 |
$27.88 |
$113.50 |
$28.38 |
| |
| |
|
PPO |
48 |
$2,186.00 |
$708.00 |
$14.75 |
$499.00 |
$10.40 |
| 22 |
THERAPY |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
48 |
$2,186.00 |
$708.00 |
$14.75 |
$499.00 |
$10.40 |
| |
| |
|
PPO |
2 |
$284.31 |
$37.73 |
$18.87 |
$0.00 |
$0.00 |
| 25 |
OTHER MEDICAL SERVICES |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$284.31 |
$37.73 |
$18.87 |
$0.00 |
$0.00 |
| |
| |
|
PPO |
1 |
$38.54 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| 27 |
INELIGIBLE EXPENSE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$38.54 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
| |
|
PPO |
4 |
$97.00 |
$67.41 |
$16.85 |
$22.10 |
$5.53 |
| 52 |
INJECTION(S) |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
4 |
$97.00 |
$67.41 |
$16.85 |
$22.10 |
$5.53 |
| |
| |
|
PPO |
7 |
$298.00 |
$211.00 |
$30.14 |
$77.00 |
$11.00 |
| 53 |
WELL CHILD CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
7 |
$298.00 |
$211.00 |
$30.14 |
$77.00 |
$11.00 |
| |
| |
|
PPO |
2 |
$868.00 |
$0.00 |
$0.00 |
$278.00 |
$139.00 |
| 60 |
PODIATRIC CARE |
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$868.00 |
$0.00 |
$0.00 |
$278.00 |
$139.00 |
| Total Ben Type: M |
| |
|
Non-PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
PPO |
155 |
$20,701.91 |
$11,343.21 |
$73.18 |
$5,010.65 |
$32.33 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
155 |
$20,701.91 |
$11,343.21 |
$73.18 |
$5,010.65 |
$32.33 |
| |
| PPO Cnt: |
| Ben Type: CS |
| 01 |
HOSPITAL ROOM & BOARD |
Non-PPO |
2 |
$4,333.50 |
$2,683.45 |
$1,341.73 |
$0.00 |
$0.00 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
2 |
$4,333.50 |
$2,683.45 |
$1,341.73 |
$0.00 |
$0.00 |
| |
| 02 |
HOSPITAL MISC - INPATIENT |
Non-PPO |
1 |
$25,906.62 |
$23,943.37 |
$23,943.37 |
$1,512.01 |
$1,512.01 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$25,906.62 |
$23,943.37 |
$23,943.37 |
$1,512.01 |
$1,512.01 |
| |
| 03 |
HOSPITAL MISC -OUTPATIENT |
Non-PPO |
9 |
$2,216.16 |
$846.53 |
$94.06 |
$87.64 |
$9.74 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
9 |
$2,216.16 |
$846.53 |
$94.06 |
$87.64 |
$9.74 |
| |
| 04 |
SURGERY - OUTPATIENT |
Non-PPO |
1 |
$750.00 |
$449.73 |
$449.73 |
$187.84 |
$187.84 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
OOA |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| |
|
Total |
1 |
$750.00 |
$449.73 |
$449.73 |
$187.84 |
$187.84 |
| |
| 05 |
SURGERY - INPATIENT |
Non-PPO |
7 |
$5,204.00 |
$2,480.28 |
$354.33 |
$952.61 |
$136.09 |
| |
|
PPO |
0 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |