|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
IP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
OP
|
$2,662.05
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$2,555.57 |
| Rate for Payer: Aetna Commercial |
$2,049.78
|
| Rate for Payer: Anthem Medicaid |
$915.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,076.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$1,331.03
|
| Rate for Payer: Cash Price |
$1,331.03
|
| Rate for Payer: Cigna Commercial |
$2,209.50
|
| Rate for Payer: First Health Commercial |
$2,528.95
|
| Rate for Payer: Humana Commercial |
$2,262.74
|
| Rate for Payer: Humana KY Medicaid |
$915.48
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$924.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,182.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,964.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$933.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,342.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,996.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,129.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,315.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,836.81
|
| Rate for Payer: PHCS Commercial |
$2,555.57
|
| Rate for Payer: United Healthcare All Payer |
$2,342.60
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Professional
|
Both
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$20.77 |
| Rate for Payer: Aetna Commercial |
$5.64
|
| Rate for Payer: Ambetter Exchange |
$4.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.23
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.36
|
| Rate for Payer: Multiplan PHCS |
$20.77
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.67
|
| Rate for Payer: UHCCP Medicaid |
$12.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.36
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
OP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem Medicaid |
$11.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Humana KY Medicaid |
$11.90
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$12.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
IP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRVANQ 250MCG/5ML ORAL SOL
|
Facility
|
OP
|
$22.94
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
25003066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$22.02 |
| Rate for Payer: Aetna Commercial |
$17.66
|
| Rate for Payer: Anthem Medicaid |
$7.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cigna Commercial |
$19.04
|
| Rate for Payer: First Health Commercial |
$21.79
|
| Rate for Payer: Humana Commercial |
$19.50
|
| Rate for Payer: Humana KY Medicaid |
$7.89
|
| Rate for Payer: Kentucky WC Medicaid |
$7.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.19
|
| Rate for Payer: Ohio Health Group HMO |
$17.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.83
|
| Rate for Payer: PHCS Commercial |
$22.02
|
| Rate for Payer: United Healthcare All Payer |
$20.19
|
|
|
FIRVANQ 250MCG/5ML ORAL SOL
|
Facility
|
IP
|
$22.94
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
25003066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$22.02 |
| Rate for Payer: Aetna Commercial |
$17.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.89
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cigna Commercial |
$19.04
|
| Rate for Payer: First Health Commercial |
$21.79
|
| Rate for Payer: Humana Commercial |
$19.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.19
|
| Rate for Payer: Ohio Health Group HMO |
$17.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.83
|
| Rate for Payer: PHCS Commercial |
$22.02
|
| Rate for Payer: United Healthcare All Payer |
$20.19
|
|
|
FISSURECTOMY W WO SPHINECTOM(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 46200
|
| Hospital Charge Code |
761P1915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.90 |
| Max. Negotiated Rate |
$446.94 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Ambetter Exchange |
$317.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$194.43
|
| Rate for Payer: Anthem Medicaid |
$192.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$317.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$317.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$381.59
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$376.74
|
| Rate for Payer: Healthspan PPO |
$446.94
|
| Rate for Payer: Humana Medicaid |
$192.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$388.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$317.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$196.76
|
| Rate for Payer: Molina Healthcare Passport |
$192.90
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$413.39
|
| Rate for Payer: UHCCP Medicaid |
$204.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$317.99
|
|
|
FISSURECTOMY W WO SPHINECTOMY
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 46200
|
| Hospital Charge Code |
76101915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.90 |
| Max. Negotiated Rate |
$446.94 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Ambetter Exchange |
$317.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$194.43
|
| Rate for Payer: Anthem Medicaid |
$192.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$317.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$317.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$381.59
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$376.74
|
| Rate for Payer: Healthspan PPO |
$446.94
|
| Rate for Payer: Humana Medicaid |
$192.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$388.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$317.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$196.76
|
| Rate for Payer: Molina Healthcare Passport |
$192.90
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$413.39
|
| Rate for Payer: UHCCP Medicaid |
$204.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$317.99
|
|
|
FISSURECTOMY W WO SPHINECTOMY
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 46200
|
| Hospital Charge Code |
76101915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$565.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$448.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
FISSURECTOMY W WO SPHINECTOMY
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 46200
|
| Hospital Charge Code |
76101915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$223.53 |
| Max. Negotiated Rate |
$3,547.47 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,533.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,547.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,420.78
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.53
|
| Rate for Payer: Humana Medicare Advantage |
$2,533.91
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$565.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$448.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
FISTULA REPAIR RECTO VAG
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 57300
|
| Hospital Charge Code |
76102188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
FISTULA REPAIR RECTO VAG
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 57300
|
| Hospital Charge Code |
76102188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$619.02 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
FISTULA REPAIR RECTO VAG
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 57300
|
| Hospital Charge Code |
76102188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$452.33 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$798.65
|
| Rate for Payer: Ambetter Exchange |
$575.09
|
| Rate for Payer: Anthem Medicaid |
$452.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$575.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$575.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$690.11
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$763.26
|
| Rate for Payer: Healthspan PPO |
$773.29
|
| Rate for Payer: Humana Medicaid |
$452.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$709.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$575.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$575.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$461.38
|
| Rate for Payer: Molina Healthcare Passport |
$452.33
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$747.62
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$456.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$575.09
|
|
|
FISTULA REPAIR RECTO VAG(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 57300
|
| Hospital Charge Code |
761P2188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$452.33 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$798.65
|
| Rate for Payer: Ambetter Exchange |
$575.09
|
| Rate for Payer: Anthem Medicaid |
$452.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$575.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$575.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$690.11
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$763.26
|
| Rate for Payer: Healthspan PPO |
$773.29
|
| Rate for Payer: Humana Medicaid |
$452.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$709.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$575.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$575.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$461.38
|
| Rate for Payer: Molina Healthcare Passport |
$452.33
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$747.62
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$456.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$575.09
|
|
|
FISTULA REPAIR URETHROVAG
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 57310
|
| Hospital Charge Code |
76102190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$306.53 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$734.44
|
| Rate for Payer: Ambetter Exchange |
$464.68
|
| Rate for Payer: Anthem Medicaid |
$306.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$464.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$464.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$557.62
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$677.56
|
| Rate for Payer: Healthspan PPO |
$711.12
|
| Rate for Payer: Humana Medicaid |
$306.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$599.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$464.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$312.66
|
| Rate for Payer: Molina Healthcare Passport |
$306.53
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$604.08
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$309.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$464.68
|
|
|
FISTULA REPAIR URETHROVAG
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 57310
|
| Hospital Charge Code |
76102190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
FISTULA REPAIR URETHROVAG
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 57310
|
| Hospital Charge Code |
76102190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$687.80 |
| Max. Negotiated Rate |
$9,565.72 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,832.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,565.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,224.09
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Humana Medicare Advantage |
$6,832.66
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,199.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
FISTULA REPAIR URETHROVAG(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 57310
|
| Hospital Charge Code |
761P2190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$306.53 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$734.44
|
| Rate for Payer: Ambetter Exchange |
$464.68
|
| Rate for Payer: Anthem Medicaid |
$306.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$464.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$464.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$557.62
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$677.56
|
| Rate for Payer: Healthspan PPO |
$711.12
|
| Rate for Payer: Humana Medicaid |
$306.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$599.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$464.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$312.66
|
| Rate for Payer: Molina Healthcare Passport |
$306.53
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$604.08
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$309.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$464.68
|
|
|
FIXATION KT SECONDARY ACL/PCL
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
FIXATION KT SECONDARY ACL/PCL
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
FIXATION OF ANKLE JOINT
|
Professional
|
Both
|
$388.00
|
|
|
Service Code
|
HCPCS 27860
|
| Hospital Charge Code |
76102938
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.07 |
| Max. Negotiated Rate |
$285.54 |
| Rate for Payer: Aetna Commercial |
$263.54
|
| Rate for Payer: Ambetter Exchange |
$155.86
|
| Rate for Payer: Anthem Medicaid |
$110.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$155.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.03
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cigna Commercial |
$285.54
|
| Rate for Payer: Healthspan PPO |
$238.71
|
| Rate for Payer: Humana Medicaid |
$110.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$216.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$155.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.27
|
| Rate for Payer: Molina Healthcare Passport |
$110.07
|
| Rate for Payer: Multiplan PHCS |
$232.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$202.62
|
| Rate for Payer: UHCCP Medicaid |
$135.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$155.86
|
|
|
FIXATION OF ANKLE JOINT
|
Facility
|
IP
|
$388.00
|
|
|
Service Code
|
HCPCS 27860
|
| Hospital Charge Code |
76102938
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.40 |
| Max. Negotiated Rate |
$372.48 |
| Rate for Payer: Aetna Commercial |
$298.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$302.64
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cigna Commercial |
$322.04
|
| Rate for Payer: First Health Commercial |
$368.60
|
| Rate for Payer: Humana Commercial |
$329.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$318.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$286.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$116.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$341.44
|
| Rate for Payer: Ohio Health Group HMO |
$291.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$310.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$337.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.72
|
| Rate for Payer: PHCS Commercial |
$372.48
|
| Rate for Payer: United Healthcare All Payer |
$341.44
|
|
|
FIXATION OF ANKLE JOINT
|
Facility
|
OP
|
$388.00
|
|
|
Service Code
|
HCPCS 27860
|
| Hospital Charge Code |
76102938
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.43 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$298.76
|
| Rate for Payer: Anthem Medicaid |
$133.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$302.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cigna Commercial |
$322.04
|
| Rate for Payer: First Health Commercial |
$368.60
|
| Rate for Payer: Humana Commercial |
$329.80
|
| Rate for Payer: Humana KY Medicaid |
$133.43
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$134.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$318.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$286.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$136.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$341.44
|
| Rate for Payer: Ohio Health Group HMO |
$291.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$310.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$337.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.72
|
| Rate for Payer: PHCS Commercial |
$372.48
|
| Rate for Payer: United Healthcare All Payer |
$341.44
|
|
|
FIXATION OF KNEE JOINT
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 27570
|
| Hospital Charge Code |
76100878
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$102.53 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$212.88
|
| Rate for Payer: Ambetter Exchange |
$147.21
|
| Rate for Payer: Anthem Medicaid |
$102.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.65
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$232.52
|
| Rate for Payer: Healthspan PPO |
$192.82
|
| Rate for Payer: Humana Medicaid |
$102.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.58
|
| Rate for Payer: Molina Healthcare Passport |
$102.53
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.37
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.21
|
|
