|
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: Ambetter Exchange |
$987.11
|
| Rate for Payer: Anthem Medicaid |
$886.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$987.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$987.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,184.53
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$987.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.11
|
| 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 |
$1,283.24
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$895.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$987.11
|
|
|
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 |
$790.97 |
| Max. Negotiated Rate |
$13,467.66 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,619.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,467.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,986.68
|
| 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 |
$9,619.76
|
| 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 |
$11,543.71
|
| 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 |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| 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 |
$1,530.62 |
| Rate for Payer: Aetna Commercial |
$1,530.62
|
| Rate for Payer: Ambetter Exchange |
$859.83
|
| Rate for Payer: Anthem Medicaid |
$780.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$859.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$859.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,031.80
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$859.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$859.83
|
| 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 |
$1,117.78
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$788.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$859.83
|
|
|
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 |
$690.00 |
| 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 |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| 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(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 |
$1,530.62 |
| Rate for Payer: Aetna Commercial |
$1,530.62
|
| Rate for Payer: Ambetter Exchange |
$859.83
|
| Rate for Payer: Anthem Medicaid |
$780.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$859.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$859.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,031.80
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$859.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$859.83
|
| 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 |
$1,117.78
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$788.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$859.83
|
|
|
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 |
$1,961.02 |
| Rate for Payer: Aetna Commercial |
$1,961.02
|
| Rate for Payer: Ambetter Exchange |
$1,154.46
|
| Rate for Payer: Anthem Medicaid |
$999.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,154.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,154.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,385.35
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,154.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,154.46
|
| 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 |
$1,500.80
|
| Rate for Payer: UHCCP Medicaid |
$1,067.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,009.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,154.46
|
|
|
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 |
$1,048.89 |
| Max. Negotiated Rate |
$13,467.66 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem Medicaid |
$1,048.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,619.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,467.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,986.68
|
| 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 |
$1,048.89
|
| Rate for Payer: Humana Medicare Advantage |
$9,619.76
|
| 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 |
$11,543.71
|
| 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 |
$2,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,653.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,104.50
|
| 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
|
Facility
|
IP
|
$3,050.00
|
|
|
Service Code
|
HCPCS 58573
|
| Hospital Charge Code |
76102242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$915.00 |
| 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 |
$2,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,653.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,104.50
|
| 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 |
$1,961.02 |
| Rate for Payer: Aetna Commercial |
$1,961.02
|
| Rate for Payer: Ambetter Exchange |
$1,154.46
|
| Rate for Payer: Anthem Medicaid |
$999.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,154.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,154.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,385.35
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,154.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,154.46
|
| 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 |
$1,500.80
|
| Rate for Payer: UHCCP Medicaid |
$1,067.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,009.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,154.46
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG L
|
Facility
|
OP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem Medicaid |
$7,758.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Humana KY Medicaid |
$7,758.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,837.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG L
|
Facility
|
IP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG R
|
Facility
|
OP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem Medicaid |
$7,758.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Humana KY Medicaid |
$7,758.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,837.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 LG R
|
Facility
|
IP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDL
|
Facility
|
IP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDL
|
Facility
|
OP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem Medicaid |
$7,758.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Humana KY Medicaid |
$7,758.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,837.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDR
|
Facility
|
IP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 MEDR
|
Facility
|
OP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem Medicaid |
$7,758.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Humana KY Medicaid |
$7,758.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,837.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 SM L
|
Facility
|
IP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 SM L
|
Facility
|
OP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem Medicaid |
$7,758.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Humana KY Medicaid |
$7,758.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,837.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 SM R
|
Facility
|
OP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem Medicaid |
$7,758.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Humana KY Medicaid |
$7,758.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,837.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM DIAPHYSEAL CONE 30 SM R
|
Facility
|
IP
|
$22,561.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.41 |
| Max. Negotiated Rate |
$21,658.91 |
| Rate for Payer: Aetna Commercial |
$17,372.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,597.86
|
| Rate for Payer: Cash Price |
$11,280.68
|
| Rate for Payer: Cigna Commercial |
$18,725.93
|
| Rate for Payer: First Health Commercial |
$21,433.29
|
| Rate for Payer: Humana Commercial |
$19,177.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,500.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,628.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.34
|
| Rate for Payer: PHCS Commercial |
$21,658.91
|
| Rate for Payer: United Healthcare All Payer |
$19,854.00
|
|
|
TM FEM METAPHYSEAL CONE 35 LGL
|
Facility
|
IP
|
$26,337.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,901.28 |
| Max. Negotiated Rate |
$25,284.11 |
| Rate for Payer: Aetna Commercial |
$20,279.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,543.34
|
| Rate for Payer: Cash Price |
$13,168.81
|
| Rate for Payer: Cigna Commercial |
$21,860.22
|
| Rate for Payer: First Health Commercial |
$25,020.73
|
| Rate for Payer: Humana Commercial |
$22,386.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,596.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,437.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,901.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,177.10
|
| Rate for Payer: Ohio Health Group HMO |
$19,753.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,070.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,913.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,172.95
|
| Rate for Payer: PHCS Commercial |
$25,284.11
|
| Rate for Payer: United Healthcare All Payer |
$23,177.10
|
|
|
TM FEM METAPHYSEAL CONE 35 LGL
|
Facility
|
OP
|
$26,337.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,901.28 |
| Max. Negotiated Rate |
$25,284.11 |
| Rate for Payer: Aetna Commercial |
$20,279.96
|
| Rate for Payer: Anthem Medicaid |
$9,057.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,543.34
|
| Rate for Payer: Cash Price |
$13,168.81
|
| Rate for Payer: Cigna Commercial |
$21,860.22
|
| Rate for Payer: First Health Commercial |
$25,020.73
|
| Rate for Payer: Humana Commercial |
$22,386.97
|
| Rate for Payer: Humana KY Medicaid |
$9,057.50
|
| Rate for Payer: Kentucky WC Medicaid |
$9,149.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,596.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,437.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,901.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,239.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,177.10
|
| Rate for Payer: Ohio Health Group HMO |
$19,753.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,070.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,913.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,172.95
|
| Rate for Payer: PHCS Commercial |
$25,284.11
|
| Rate for Payer: United Healthcare All Payer |
$23,177.10
|
|
|
TM FEM METAPHYSEAL CONE 35 LGR
|
Facility
|
IP
|
$26,337.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,901.28 |
| Max. Negotiated Rate |
$25,284.11 |
| Rate for Payer: Aetna Commercial |
$20,279.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,543.34
|
| Rate for Payer: Cash Price |
$13,168.81
|
| Rate for Payer: Cigna Commercial |
$21,860.22
|
| Rate for Payer: First Health Commercial |
$25,020.73
|
| Rate for Payer: Humana Commercial |
$22,386.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,596.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,437.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,901.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,177.10
|
| Rate for Payer: Ohio Health Group HMO |
$19,753.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,070.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,913.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,172.95
|
| Rate for Payer: PHCS Commercial |
$25,284.11
|
| Rate for Payer: United Healthcare All Payer |
$23,177.10
|
|
|
TM FEM METAPHYSEAL CONE 35 LGR
|
Facility
|
OP
|
$26,337.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,901.28 |
| Max. Negotiated Rate |
$25,284.11 |
| Rate for Payer: Aetna Commercial |
$20,279.96
|
| Rate for Payer: Anthem Medicaid |
$9,057.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,543.34
|
| Rate for Payer: Cash Price |
$13,168.81
|
| Rate for Payer: Cigna Commercial |
$21,860.22
|
| Rate for Payer: First Health Commercial |
$25,020.73
|
| Rate for Payer: Humana Commercial |
$22,386.97
|
| Rate for Payer: Humana KY Medicaid |
$9,057.50
|
| Rate for Payer: Kentucky WC Medicaid |
$9,149.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,596.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,437.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,901.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,239.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,177.10
|
| Rate for Payer: Ohio Health Group HMO |
$19,753.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,070.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,913.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,172.95
|
| Rate for Payer: PHCS Commercial |
$25,284.11
|
| Rate for Payer: United Healthcare All Payer |
$23,177.10
|
|
