|
ANTACID CHOICE (MI-ACID)(15ML)
|
Facility
|
IP
|
$11.78
|
|
|
Service Code
|
NDC 121176230
|
| Hospital Charge Code |
25002836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.31 |
| Rate for Payer: Aetna Commercial |
$9.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.19
|
| Rate for Payer: Cash Price |
$5.89
|
| Rate for Payer: Cigna Commercial |
$9.78
|
| Rate for Payer: First Health Commercial |
$11.19
|
| Rate for Payer: Humana Commercial |
$10.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.37
|
| Rate for Payer: Ohio Health Group HMO |
$8.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.65
|
| Rate for Payer: PHCS Commercial |
$11.31
|
| Rate for Payer: United Healthcare All Payer |
$10.37
|
|
|
ANTACID CHOICE (MI-ACID)(15ML)
|
Facility
|
OP
|
$11.78
|
|
|
Service Code
|
NDC 121176230
|
| Hospital Charge Code |
25002836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.31 |
| Rate for Payer: Aetna Commercial |
$9.07
|
| Rate for Payer: Anthem Medicaid |
$4.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.19
|
| Rate for Payer: Cash Price |
$5.89
|
| Rate for Payer: Cigna Commercial |
$9.78
|
| Rate for Payer: First Health Commercial |
$11.19
|
| Rate for Payer: Humana Commercial |
$10.01
|
| Rate for Payer: Humana KY Medicaid |
$4.05
|
| Rate for Payer: Kentucky WC Medicaid |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.37
|
| Rate for Payer: Ohio Health Group HMO |
$8.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.65
|
| Rate for Payer: PHCS Commercial |
$11.31
|
| Rate for Payer: United Healthcare All Payer |
$10.37
|
|
|
ANTEPARTUM CARE 4-6 VISITS
|
Professional
|
Both
|
$1,220.00
|
|
|
Service Code
|
HCPCS 59425
|
| Hospital Charge Code |
72000019
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$1,220.00 |
| Rate for Payer: Aetna Commercial |
$564.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$222.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,220.00
|
| Rate for Payer: Cash Price |
$610.00
|
| Rate for Payer: Cash Price |
$610.00
|
| Rate for Payer: Cigna Commercial |
$643.14
|
| Rate for Payer: Healthspan PPO |
$510.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$427.65
|
| Rate for Payer: Multiplan PHCS |
$732.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$854.00
|
| Rate for Payer: UHCCP Medicaid |
$233.10
|
|
|
ANTEPARTUM CARE 4-6 VISITS
|
Facility
|
OP
|
$1,220.00
|
|
|
Service Code
|
HCPCS 59425
|
| Hospital Charge Code |
72000019
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$158.60 |
| Max. Negotiated Rate |
$1,171.20 |
| Rate for Payer: Aetna Commercial |
$939.40
|
| Rate for Payer: Anthem Medicaid |
$419.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$951.60
|
| Rate for Payer: Cash Price |
$610.00
|
| Rate for Payer: Cigna Commercial |
$1,012.60
|
| Rate for Payer: First Health Commercial |
$1,159.00
|
| Rate for Payer: Humana Commercial |
$1,037.00
|
| Rate for Payer: Humana KY Medicaid |
$419.56
|
| Rate for Payer: Kentucky WC Medicaid |
$423.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,000.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$900.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$366.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$427.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,073.60
|
| Rate for Payer: Ohio Health Group HMO |
$915.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.20
|
| Rate for Payer: PHCS Commercial |
$1,171.20
|
| Rate for Payer: United Healthcare All Payer |
$1,073.60
|
|
|
ANTEPARTUM CARE 4-6 VISITS
|
Facility
|
IP
|
$1,220.00
|
|
|
Service Code
|
HCPCS 59425
|
| Hospital Charge Code |
72000019
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$158.60 |
| Max. Negotiated Rate |
$1,171.20 |
| Rate for Payer: Aetna Commercial |
$939.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$951.60
|
| Rate for Payer: Cash Price |
$610.00
|
| Rate for Payer: Cigna Commercial |
$1,012.60
|
| Rate for Payer: First Health Commercial |
$1,159.00
|
| Rate for Payer: Humana Commercial |
$1,037.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,000.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$900.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$366.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,073.60
|
| Rate for Payer: Ohio Health Group HMO |
$915.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$378.20
|
| Rate for Payer: PHCS Commercial |
$1,171.20
|
| Rate for Payer: United Healthcare All Payer |
$1,073.60
|
|
|
ANTEPARTUM CARE 4-6 VISITS(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 59425
|
| Hospital Charge Code |
720P0019
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$564.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$222.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$643.14
|
| Rate for Payer: Healthspan PPO |
$510.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$427.65
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$233.10
|
|
|
ANTEPARTUM CARE 4-6 VISITS(T
|
Facility
|
IP
|
$520.00
|
|
|
Service Code
|
HCPCS 59425
|
| Hospital Charge Code |
720T0019
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$499.20 |
| Rate for Payer: Aetna Commercial |
$400.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$405.60
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$431.60
|
| Rate for Payer: First Health Commercial |
$494.00
|
| Rate for Payer: Humana Commercial |
$442.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$426.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$457.60
|
| Rate for Payer: Ohio Health Group HMO |
$390.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.20
|
| Rate for Payer: PHCS Commercial |
$499.20
|
| Rate for Payer: United Healthcare All Payer |
$457.60
|
|
|
ANTEPARTUM CARE 4-6 VISITS(T
|
Facility
|
OP
|
$520.00
|
|
|
Service Code
|
HCPCS 59425
|
| Hospital Charge Code |
720T0019
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$499.20 |
| Rate for Payer: Aetna Commercial |
$400.40
|
| Rate for Payer: Anthem Medicaid |
$178.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$405.60
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$431.60
|
| Rate for Payer: First Health Commercial |
$494.00
|
| Rate for Payer: Humana Commercial |
$442.00
|
| Rate for Payer: Humana KY Medicaid |
$178.83
|
| Rate for Payer: Kentucky WC Medicaid |
$180.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$426.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$457.60
|
| Rate for Payer: Ohio Health Group HMO |
$390.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.20
|
| Rate for Payer: PHCS Commercial |
$499.20
|
| Rate for Payer: United Healthcare All Payer |
$457.60
|
|
|
ANTEPARTUM CARE 7 MORE VISIT
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 59426
|
| Hospital Charge Code |
72000020
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
ANTEPARTUM CARE 7 MORE VISIT
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 59426
|
| Hospital Charge Code |
72000020
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
ANTEPARTUM CARE 7 MORE VISIT
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 59426
|
| Hospital Charge Code |
720P0020
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$406.63 |
| Max. Negotiated Rate |
$1,146.72 |
| Rate for Payer: Aetna Commercial |
$997.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$406.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,146.72
|
| Rate for Payer: Healthspan PPO |
$911.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,088.00
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$426.96
|
|
|
ANTEPARTUM CARE 7 MORE VISIT
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 59426
|
| Hospital Charge Code |
72000020
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$406.63 |
| Max. Negotiated Rate |
$1,146.72 |
| Rate for Payer: Aetna Commercial |
$997.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$406.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,146.72
|
| Rate for Payer: Healthspan PPO |
$911.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,088.00
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$426.96
|
|
|
ANTERIOR COLPORRHAPHY
|
Facility
|
IP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 57240
|
| Hospital Charge Code |
76102180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$1,248.00 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
ANTERIOR COLPORRHAPHY
|
Facility
|
OP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 57240
|
| Hospital Charge Code |
76102180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$6,021.69 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem Medicaid |
$447.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,301.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,021.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,806.63
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Humana KY Medicaid |
$447.07
|
| Rate for Payer: Humana Medicare Advantage |
$4,301.21
|
| Rate for Payer: Kentucky WC Medicaid |
$451.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,161.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$456.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
ANTERIOR COLPORRHAPHY
|
Professional
|
Both
|
$1,300.00
|
|
|
Service Code
|
HCPCS 57240
|
| Hospital Charge Code |
76102180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$382.11 |
| Max. Negotiated Rate |
$1,300.00 |
| Rate for Payer: Aetna Commercial |
$984.44
|
| Rate for Payer: Anthem Medicaid |
$382.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,300.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$896.98
|
| Rate for Payer: Healthspan PPO |
$953.19
|
| Rate for Payer: Humana Medicaid |
$382.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$863.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.75
|
| Rate for Payer: Molina Healthcare Passport |
$382.11
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.93
|
|
|
ANTERIOR COLPORRHAPHY(P
|
Professional
|
Both
|
$1,300.00
|
|
|
Service Code
|
HCPCS 57240
|
| Hospital Charge Code |
761P2180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$382.11 |
| Max. Negotiated Rate |
$1,300.00 |
| Rate for Payer: Aetna Commercial |
$984.44
|
| Rate for Payer: Anthem Medicaid |
$382.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,300.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$896.98
|
| Rate for Payer: Healthspan PPO |
$953.19
|
| Rate for Payer: Humana Medicaid |
$382.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$863.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.75
|
| Rate for Payer: Molina Healthcare Passport |
$382.11
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.93
|
|
|
ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED
|
Facility
|
OP
|
$6,021.69
|
|
|
Service Code
|
CPT 57240
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,301.21 |
| Max. Negotiated Rate |
$6,021.69 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,301.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,021.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,806.63
|
| Rate for Payer: Humana Medicare Advantage |
$4,301.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,161.45
|
|
|
ANTERIOR TIBIAL TUBERCLEPLASTY
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
HCPCS 27418
|
| Hospital Charge Code |
76100838
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.50 |
| Max. Negotiated Rate |
$1,344.65 |
| Rate for Payer: Aetna Commercial |
$1,230.69
|
| Rate for Payer: Anthem Medicaid |
$661.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,030.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$1,344.65
|
| Rate for Payer: Healthspan PPO |
$1,114.75
|
| Rate for Payer: Humana Medicaid |
$661.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,033.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$674.36
|
| Rate for Payer: Molina Healthcare Passport |
$661.14
|
| Rate for Payer: Multiplan PHCS |
$618.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$721.00
|
| Rate for Payer: UHCCP Medicaid |
$360.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$667.75
|
|
|
ANTERIOR TIBIAL TUBERCLEPLASTY
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 27418
|
| Hospital Charge Code |
76100838
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.90 |
| Max. Negotiated Rate |
$988.80 |
| Rate for Payer: Aetna Commercial |
$793.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$854.90
|
| Rate for Payer: First Health Commercial |
$978.50
|
| Rate for Payer: Humana Commercial |
$875.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$844.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$760.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$906.40
|
| Rate for Payer: Ohio Health Group HMO |
$772.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$319.30
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
ANTERIOR TIBIAL TUBERCLEPLASTY
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 27418
|
| Hospital Charge Code |
76100838
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.90 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$793.10
|
| Rate for Payer: Anthem Medicaid |
$354.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$854.90
|
| Rate for Payer: First Health Commercial |
$978.50
|
| Rate for Payer: Humana Commercial |
$875.50
|
| Rate for Payer: Humana KY Medicaid |
$354.22
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$357.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$844.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$760.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$361.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$906.40
|
| Rate for Payer: Ohio Health Group HMO |
$772.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$319.30
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
ANTERIOR TIBIAL TUBERCLEPLASTY
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
HCPCS 27418
|
| Hospital Charge Code |
761P0838
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.50 |
| Max. Negotiated Rate |
$1,344.65 |
| Rate for Payer: Aetna Commercial |
$1,230.69
|
| Rate for Payer: Anthem Medicaid |
$661.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,030.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$1,344.65
|
| Rate for Payer: Healthspan PPO |
$1,114.75
|
| Rate for Payer: Humana Medicaid |
$661.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,033.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$674.36
|
| Rate for Payer: Molina Healthcare Passport |
$661.14
|
| Rate for Payer: Multiplan PHCS |
$618.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$721.00
|
| Rate for Payer: UHCCP Medicaid |
$360.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$667.75
|
|
|
ANTERIOR VESICOUR/URETHROPOX(P
|
Professional
|
Both
|
$2,400.00
|
|
|
Service Code
|
HCPCS 51841
|
| Hospital Charge Code |
761P2074
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$686.33 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,238.97
|
| Rate for Payer: Anthem Medicaid |
$686.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,400.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cigna Commercial |
$1,150.76
|
| Rate for Payer: Healthspan PPO |
$990.67
|
| Rate for Payer: Humana Medicaid |
$686.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,064.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$700.06
|
| Rate for Payer: Molina Healthcare Passport |
$686.33
|
| Rate for Payer: Multiplan PHCS |
$1,440.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,680.00
|
| Rate for Payer: UHCCP Medicaid |
$840.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$693.19
|
|
|
ANTERIOR VESICOUR/URETHROPOXY
|
Facility
|
IP
|
$2,400.00
|
|
|
Service Code
|
HCPCS 51841
|
| Hospital Charge Code |
76102074
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$2,304.00 |
| Rate for Payer: Aetna Commercial |
$1,848.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,872.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cigna Commercial |
$1,992.00
|
| Rate for Payer: First Health Commercial |
$2,280.00
|
| Rate for Payer: Humana Commercial |
$2,040.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,968.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,771.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$720.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,112.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,800.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$744.00
|
| Rate for Payer: PHCS Commercial |
$2,304.00
|
| Rate for Payer: United Healthcare All Payer |
$2,112.00
|
|
|
ANTERIOR VESICOUR/URETHROPOXY
|
Facility
|
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS 51841
|
| Hospital Charge Code |
76102074
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$2,304.00 |
| Rate for Payer: Aetna Commercial |
$1,848.00
|
| Rate for Payer: Anthem Medicaid |
$825.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,872.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cigna Commercial |
$1,992.00
|
| Rate for Payer: First Health Commercial |
$2,280.00
|
| Rate for Payer: Humana Commercial |
$2,040.00
|
| Rate for Payer: Humana KY Medicaid |
$825.36
|
| Rate for Payer: Kentucky WC Medicaid |
$833.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,968.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,771.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$720.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$841.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,112.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,800.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$744.00
|
| Rate for Payer: PHCS Commercial |
$2,304.00
|
| Rate for Payer: United Healthcare All Payer |
$2,112.00
|
|
|
ANTERIOR VESICOUR/URETHROPOXY
|
Professional
|
Both
|
$2,400.00
|
|
|
Service Code
|
HCPCS 51841
|
| Hospital Charge Code |
76102074
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$686.33 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,238.97
|
| Rate for Payer: Anthem Medicaid |
$686.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,400.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cigna Commercial |
$1,150.76
|
| Rate for Payer: Healthspan PPO |
$990.67
|
| Rate for Payer: Humana Medicaid |
$686.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,064.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$700.06
|
| Rate for Payer: Molina Healthcare Passport |
$686.33
|
| Rate for Payer: Multiplan PHCS |
$1,440.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,680.00
|
| Rate for Payer: UHCCP Medicaid |
$840.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$693.19
|
|
