|
TIVICAY 50MG TABLET
|
Facility
|
IP
|
$147.25
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
25003525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$141.36 |
| Rate for Payer: Aetna Commercial |
$113.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.86
|
| Rate for Payer: Cash Price |
$73.62
|
| Rate for Payer: Cigna Commercial |
$122.22
|
| Rate for Payer: First Health Commercial |
$139.89
|
| Rate for Payer: Humana Commercial |
$125.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.58
|
| Rate for Payer: Ohio Health Group HMO |
$110.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.65
|
| Rate for Payer: PHCS Commercial |
$141.36
|
| Rate for Payer: United Healthcare All Payer |
$129.58
|
|
|
TIVICAY 50MG TABLET
|
Facility
|
OP
|
$147.25
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
25003525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$141.36 |
| Rate for Payer: Aetna Commercial |
$113.38
|
| Rate for Payer: Anthem Medicaid |
$50.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.86
|
| Rate for Payer: Cash Price |
$73.62
|
| Rate for Payer: Cigna Commercial |
$122.22
|
| Rate for Payer: First Health Commercial |
$139.89
|
| Rate for Payer: Humana Commercial |
$125.16
|
| Rate for Payer: Humana KY Medicaid |
$50.64
|
| Rate for Payer: Kentucky WC Medicaid |
$51.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.58
|
| Rate for Payer: Ohio Health Group HMO |
$110.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.65
|
| Rate for Payer: PHCS Commercial |
$141.36
|
| Rate for Payer: United Healthcare All Payer |
$129.58
|
|
|
TLH UTERUS 250 G OR LESS
|
Facility
|
IP
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
76102240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$256.10 |
| Max. Negotiated Rate |
$1,891.20 |
| Rate for Payer: Aetna Commercial |
$1,516.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,536.60
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,635.10
|
| Rate for Payer: First Health Commercial |
$1,871.50
|
| Rate for Payer: Humana Commercial |
$1,674.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,615.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,453.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$591.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,733.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,477.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$394.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$610.70
|
| Rate for Payer: PHCS Commercial |
$1,891.20
|
| Rate for Payer: United Healthcare All Payer |
$1,733.60
|
|
|
TLH UTERUS 250 G OR LESS
|
Professional
|
Both
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
76102240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.50 |
| Max. Negotiated Rate |
$1,970.00 |
| Rate for Payer: Aetna Commercial |
$1,398.46
|
| Rate for Payer: Anthem Medicaid |
$712.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,970.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,311.59
|
| Rate for Payer: Healthspan PPO |
$1,354.06
|
| Rate for Payer: Humana Medicaid |
$712.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,202.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$727.23
|
| Rate for Payer: Molina Healthcare Passport |
$712.97
|
| Rate for Payer: Multiplan PHCS |
$1,182.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,379.00
|
| Rate for Payer: UHCCP Medicaid |
$689.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$720.10
|
|
|
TLH UTERUS 250 G OR LESS
|
Facility
|
OP
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
76102240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$256.10 |
| Max. Negotiated Rate |
$12,462.13 |
| Rate for Payer: Aetna Commercial |
$1,516.90
|
| Rate for Payer: Anthem Medicaid |
$677.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,901.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,536.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,462.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,017.05
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,635.10
|
| Rate for Payer: First Health Commercial |
$1,871.50
|
| Rate for Payer: Humana Commercial |
$1,674.50
|
| Rate for Payer: Humana KY Medicaid |
$677.48
|
| Rate for Payer: Humana Medicare Advantage |
$8,901.52
|
| Rate for Payer: Kentucky WC Medicaid |
$684.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,615.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,453.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,681.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$691.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,733.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,477.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$394.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$610.70
|
| Rate for Payer: PHCS Commercial |
$1,891.20
|
| Rate for Payer: United Healthcare All Payer |
$1,733.60
|
|
|
TLH UTERUS 250 G OR LESS(P
|
Professional
|
Both
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58570
|
| Hospital Charge Code |
761P2240
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.50 |
| Max. Negotiated Rate |
$1,970.00 |
| Rate for Payer: Aetna Commercial |
$1,398.46
|
| Rate for Payer: Anthem Medicaid |
$712.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,970.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cash Price |
$985.00
|
| Rate for Payer: Cigna Commercial |
$1,311.59
|
| Rate for Payer: Healthspan PPO |
$1,354.06
|
| Rate for Payer: Humana Medicaid |
$712.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,202.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$727.23
|
| Rate for Payer: Molina Healthcare Passport |
$712.97
|
| Rate for Payer: Multiplan PHCS |
$1,182.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,379.00
|
| Rate for Payer: UHCCP Medicaid |
$689.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$720.10
|
|
|
TLH UTERUS OVER 250 G
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
36001275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$163.15 |
| Max. Negotiated Rate |
$12,462.13 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem Medicaid |
$431.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,901.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,462.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,017.05
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Humana KY Medicaid |
$431.59
|
| Rate for Payer: Humana Medicare Advantage |
$8,901.52
|
| Rate for Payer: Kentucky WC Medicaid |
$435.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,681.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$440.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$251.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.05
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
TLH UTERUS OVER 250 G
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
36001275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$1,741.69 |
| Rate for Payer: Aetna Commercial |
$1,741.69
|
| Rate for Payer: Anthem Medicaid |
$886.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,255.00
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,629.36
|
| Rate for Payer: Healthspan PPO |
$1,686.40
|
| Rate for Payer: Humana Medicaid |
$886.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,496.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$903.96
|
| Rate for Payer: Molina Healthcare Passport |
$886.24
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$878.50
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$895.10
|
|
|
TLH UTERUS OVER 250 G
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
360P1275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$1,741.69 |
| Rate for Payer: Aetna Commercial |
$1,741.69
|
| Rate for Payer: Anthem Medicaid |
$886.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,255.00
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,629.36
|
| Rate for Payer: Healthspan PPO |
$1,686.40
|
| Rate for Payer: Humana Medicaid |
$886.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,496.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$903.96
|
| Rate for Payer: Molina Healthcare Passport |
$886.24
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$878.50
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$895.10
|
|
|
TLH UTERUS OVER 250 G
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 58572
|
| Hospital Charge Code |
36001275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$163.15 |
| Max. Negotiated Rate |
$1,204.80 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$251.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.05
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
TLH W/T/O 250 G OR LESS
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58571
|
| Hospital Charge Code |
76102241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
TLH W/T/O 250 G OR LESS
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58571
|
| Hospital Charge Code |
76102241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$12,462.13 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,901.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,462.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,017.05
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Humana KY Medicaid |
$790.97
|
| Rate for Payer: Humana Medicare Advantage |
$8,901.52
|
| Rate for Payer: Kentucky WC Medicaid |
$799.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,681.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
TLH W/T/O 250 G OR LESS
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58571
|
| Hospital Charge Code |
76102241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$780.91 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$1,530.62
|
| Rate for Payer: Anthem Medicaid |
$780.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,435.07
|
| Rate for Payer: Healthspan PPO |
$1,482.03
|
| Rate for Payer: Humana Medicaid |
$780.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,333.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$796.53
|
| Rate for Payer: Molina Healthcare Passport |
$780.91
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$788.72
|
|
|
TLH W/T/O 250 G OR LESS(P
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58571
|
| Hospital Charge Code |
761P2241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$780.91 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$1,530.62
|
| Rate for Payer: Anthem Medicaid |
$780.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,435.07
|
| Rate for Payer: Healthspan PPO |
$1,482.03
|
| Rate for Payer: Humana Medicaid |
$780.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,333.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$796.53
|
| Rate for Payer: Molina Healthcare Passport |
$780.91
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$788.72
|
|
|
TLH W/T/O UTERUS OVER 250 G
|
Facility
|
OP
|
$3,050.00
|
|
|
Service Code
|
HCPCS 58573
|
| Hospital Charge Code |
76102242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$396.50 |
| Max. Negotiated Rate |
$12,462.13 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem Medicaid |
$1,048.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,901.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,462.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,017.05
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$2,531.50
|
| Rate for Payer: First Health Commercial |
$2,897.50
|
| Rate for Payer: Humana Commercial |
$2,592.50
|
| Rate for Payer: Humana KY Medicaid |
$1,048.90
|
| Rate for Payer: Humana Medicare Advantage |
$8,901.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,059.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,501.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,250.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,681.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,069.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,684.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,287.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$396.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$945.50
|
| Rate for Payer: PHCS Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare All Payer |
$2,684.00
|
|
|
TLH W/T/O UTERUS OVER 250 G
|
Professional
|
Both
|
$3,050.00
|
|
|
Service Code
|
HCPCS 58573
|
| Hospital Charge Code |
76102242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$999.29 |
| Max. Negotiated Rate |
$3,050.00 |
| Rate for Payer: Aetna Commercial |
$1,961.02
|
| Rate for Payer: Anthem Medicaid |
$999.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,050.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$1,835.13
|
| Rate for Payer: Healthspan PPO |
$1,898.77
|
| Rate for Payer: Humana Medicaid |
$999.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,708.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,019.28
|
| Rate for Payer: Molina Healthcare Passport |
$999.29
|
| Rate for Payer: Multiplan PHCS |
$1,830.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,135.00
|
| Rate for Payer: UHCCP Medicaid |
$1,067.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,009.28
|
|
|
TLH W/T/O UTERUS OVER 250 G
|
Facility
|
IP
|
$3,050.00
|
|
|
Service Code
|
HCPCS 58573
|
| Hospital Charge Code |
76102242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$396.50 |
| Max. Negotiated Rate |
$2,928.00 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$2,531.50
|
| Rate for Payer: First Health Commercial |
$2,897.50
|
| Rate for Payer: Humana Commercial |
$2,592.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,501.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,250.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$915.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,684.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,287.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$396.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$945.50
|
| Rate for Payer: PHCS Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare All Payer |
$2,684.00
|
|
|
TLH W/T/O UTERUS OVER 250 G(P
|
Professional
|
Both
|
$3,050.00
|
|
|
Service Code
|
HCPCS 58573
|
| Hospital Charge Code |
761P2242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$999.29 |
| Max. Negotiated Rate |
$3,050.00 |
| Rate for Payer: Aetna Commercial |
$1,961.02
|
| Rate for Payer: Anthem Medicaid |
$999.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,050.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$1,835.13
|
| Rate for Payer: Healthspan PPO |
$1,898.77
|
| Rate for Payer: Humana Medicaid |
$999.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,708.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,019.28
|
| Rate for Payer: Molina Healthcare Passport |
$999.29
|
| Rate for Payer: Multiplan PHCS |
$1,830.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,135.00
|
| Rate for Payer: UHCCP Medicaid |
$1,067.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,009.28
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG L
|
Facility
|
OP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem Medicaid |
$7,529.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Humana KY Medicaid |
$7,529.02
|
| Rate for Payer: Kentucky WC Medicaid |
$7,605.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,680.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG L
|
Facility
|
IP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG R
|
Facility
|
OP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem Medicaid |
$7,529.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Humana KY Medicaid |
$7,529.02
|
| Rate for Payer: Kentucky WC Medicaid |
$7,605.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,680.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG R
|
Facility
|
IP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDL
|
Facility
|
OP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem Medicaid |
$7,529.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Humana KY Medicaid |
$7,529.02
|
| Rate for Payer: Kentucky WC Medicaid |
$7,605.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,680.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDL
|
Facility
|
IP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDR
|
Facility
|
OP
|
$21,893.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,846.10 |
| Max. Negotiated Rate |
$21,017.34 |
| Rate for Payer: Aetna Commercial |
$16,857.66
|
| Rate for Payer: Anthem Medicaid |
$7,529.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,076.59
|
| Rate for Payer: Cash Price |
$10,946.53
|
| Rate for Payer: Cigna Commercial |
$18,171.24
|
| Rate for Payer: First Health Commercial |
$20,798.41
|
| Rate for Payer: Humana Commercial |
$18,609.10
|
| Rate for Payer: Humana KY Medicaid |
$7,529.02
|
| Rate for Payer: Kentucky WC Medicaid |
$7,605.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,952.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,157.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,567.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,680.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,265.89
|
| Rate for Payer: Ohio Health Group HMO |
$16,419.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,378.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,846.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,786.85
|
| Rate for Payer: PHCS Commercial |
$21,017.34
|
| Rate for Payer: United Healthcare All Payer |
$19,265.89
|
|
