|
VAG HYST W/BSO
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58262
|
| Hospital Charge Code |
76102215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAG HYST W/BSO
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58262
|
| Hospital Charge Code |
76102215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$685.38 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,402.11
|
| Rate for Payer: Ambetter Exchange |
$878.97
|
| Rate for Payer: Anthem Medicaid |
$685.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$878.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$878.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,054.76
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,367.84
|
| Rate for Payer: Healthspan PPO |
$1,357.60
|
| Rate for Payer: Humana Medicaid |
$685.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,200.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$878.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$878.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$699.09
|
| Rate for Payer: Molina Healthcare Passport |
$685.38
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,142.66
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$692.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$878.97
|
|
|
VAG HYST W/BSO
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58262
|
| Hospital Charge Code |
76102215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,031.70 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAG HYST W/BSO(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58262
|
| Hospital Charge Code |
761P2215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$685.38 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,402.11
|
| Rate for Payer: Ambetter Exchange |
$878.97
|
| Rate for Payer: Anthem Medicaid |
$685.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$878.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$878.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,054.76
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,367.84
|
| Rate for Payer: Healthspan PPO |
$1,357.60
|
| Rate for Payer: Humana Medicaid |
$685.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,200.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$878.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$878.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$699.09
|
| Rate for Payer: Molina Healthcare Passport |
$685.38
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,142.66
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$692.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$878.97
|
|
|
VAG HYST W/ENTEROCEL REPAIR
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58270
|
| Hospital Charge Code |
76102217
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$700.47 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,344.96
|
| Rate for Payer: Ambetter Exchange |
$847.22
|
| Rate for Payer: Anthem Medicaid |
$700.47
|
| Rate for Payer: Buckeye Individual/Medicaid |
$847.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$847.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,016.66
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,312.93
|
| Rate for Payer: Healthspan PPO |
$1,302.26
|
| Rate for Payer: Humana Medicaid |
$700.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,148.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$847.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$714.48
|
| Rate for Payer: Molina Healthcare Passport |
$700.47
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,101.39
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$707.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$847.22
|
|
|
VAG HYST W/ENTEROCEL REPAIR
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58270
|
| Hospital Charge Code |
76102217
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$962.92 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
VAG HYST W/ENTEROCEL REPAIR
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58270
|
| Hospital Charge Code |
76102217
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
VAG HYST W/ENTEROCEL REPAIR(P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58270
|
| Hospital Charge Code |
761P2217
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$700.47 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,344.96
|
| Rate for Payer: Ambetter Exchange |
$847.22
|
| Rate for Payer: Anthem Medicaid |
$700.47
|
| Rate for Payer: Buckeye Individual/Medicaid |
$847.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$847.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,016.66
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,312.93
|
| Rate for Payer: Healthspan PPO |
$1,302.26
|
| Rate for Payer: Humana Medicaid |
$700.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,148.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$847.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$714.48
|
| Rate for Payer: Molina Healthcare Passport |
$700.47
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,101.39
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$707.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$847.22
|
|
|
VAG HYST W/POSTERIOR REPAIR
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58280
|
| Hospital Charge Code |
76102218
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$758.60 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,601.59
|
| Rate for Payer: Ambetter Exchange |
$1,003.35
|
| Rate for Payer: Anthem Medicaid |
$758.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,003.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,003.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,204.02
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,561.90
|
| Rate for Payer: Healthspan PPO |
$1,550.74
|
| Rate for Payer: Humana Medicaid |
$758.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,370.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,003.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,003.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$773.77
|
| Rate for Payer: Molina Healthcare Passport |
$758.60
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,304.36
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$766.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,003.35
|
|
|
VAG HYST W/POSTERIOR REPAIR
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58280
|
| Hospital Charge Code |
76102218
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAG HYST W/POSTERIOR REPAIR
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58280
|
| Hospital Charge Code |
76102218
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAG HYST W/POSTERIOR REPAIR(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58280
|
| Hospital Charge Code |
761P2218
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$758.60 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,601.59
|
| Rate for Payer: Ambetter Exchange |
$1,003.35
|
| Rate for Payer: Anthem Medicaid |
$758.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,003.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,003.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,204.02
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,561.90
|
| Rate for Payer: Healthspan PPO |
$1,550.74
|
| Rate for Payer: Humana Medicaid |
$758.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,370.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,003.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,003.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$773.77
|
| Rate for Payer: Molina Healthcare Passport |
$758.60
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,304.36
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$766.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,003.35
|
|
|
VAGINAL HYSTERECTOMY
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
76102219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$819.58 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,760.60
|
| Rate for Payer: Ambetter Exchange |
$1,090.80
|
| Rate for Payer: Anthem Medicaid |
$819.58
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,090.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,090.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,308.96
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,724.35
|
| Rate for Payer: Healthspan PPO |
$1,704.71
|
| Rate for Payer: Humana Medicaid |
$819.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,502.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,090.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,090.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$835.97
|
| Rate for Payer: Molina Healthcare Passport |
$819.58
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,418.04
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$827.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,090.80
|
|
|
VAGINAL HYSTERECTOMY
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
76102219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAGINAL HYSTERECTOMY
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
76102219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,031.70 |
| Max. Negotiated Rate |
$9,565.72 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,832.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,565.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,224.09
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Humana Medicare Advantage |
$6,832.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,199.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
|
Facility
|
OP
|
$6,385.65
|
|
|
Service Code
|
CPT 58260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,561.18 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)
|
Facility
|
OP
|
$6,385.65
|
|
|
Service Code
|
CPT 58262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,561.18 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
|
Facility
|
OP
|
$9,565.72
|
|
|
Service Code
|
CPT 58290
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,832.66 |
| Max. Negotiated Rate |
$9,565.72 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,832.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,565.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,224.09
|
| Rate for Payer: Humana Medicare Advantage |
$6,832.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,199.19
|
|
|
VAGINAL HYSTERECTOMY(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58290
|
| Hospital Charge Code |
761P2219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$819.58 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,760.60
|
| Rate for Payer: Ambetter Exchange |
$1,090.80
|
| Rate for Payer: Anthem Medicaid |
$819.58
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,090.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,090.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,308.96
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,724.35
|
| Rate for Payer: Healthspan PPO |
$1,704.71
|
| Rate for Payer: Humana Medicaid |
$819.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,502.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,090.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,090.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$835.97
|
| Rate for Payer: Molina Healthcare Passport |
$819.58
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,418.04
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$827.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,090.80
|
|
|
VAGISIL CREAM 30 GM
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 11509000367
|
| Hospital Charge Code |
25001639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.10
|
| Rate for Payer: First Health Commercial |
$0.11
|
| Rate for Payer: Humana Commercial |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
VAGISIL CREAM 30 GM
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 11509000367
|
| Hospital Charge Code |
25001639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.09
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.10
|
| Rate for Payer: First Health Commercial |
$0.11
|
| Rate for Payer: Humana Commercial |
$0.10
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
VAGISTAT 1 6.5% ONIT 4.6G
|
Facility
|
IP
|
$30.41
|
|
|
Service Code
|
NDC 63736044101
|
| Hospital Charge Code |
25001640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$29.19 |
| Rate for Payer: Aetna Commercial |
$23.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.72
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cigna Commercial |
$25.24
|
| Rate for Payer: First Health Commercial |
$28.89
|
| Rate for Payer: Humana Commercial |
$25.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.76
|
| Rate for Payer: Ohio Health Group HMO |
$22.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.98
|
| Rate for Payer: PHCS Commercial |
$29.19
|
| Rate for Payer: United Healthcare All Payer |
$26.76
|
|
|
VAGISTAT 1 6.5% ONIT 4.6G
|
Facility
|
OP
|
$30.41
|
|
|
Service Code
|
NDC 63736044101
|
| Hospital Charge Code |
25001640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$29.19 |
| Rate for Payer: Aetna Commercial |
$23.42
|
| Rate for Payer: Anthem Medicaid |
$10.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.72
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cigna Commercial |
$25.24
|
| Rate for Payer: First Health Commercial |
$28.89
|
| Rate for Payer: Humana Commercial |
$25.85
|
| Rate for Payer: Humana KY Medicaid |
$10.46
|
| Rate for Payer: Kentucky WC Medicaid |
$10.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.76
|
| Rate for Payer: Ohio Health Group HMO |
$22.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.98
|
| Rate for Payer: PHCS Commercial |
$29.19
|
| Rate for Payer: United Healthcare All Payer |
$26.76
|
|
|
VALCYTE 450 MG TABLET
|
Facility
|
IP
|
$22.73
|
|
|
Service Code
|
NDC 31722083260
|
| Hospital Charge Code |
25001641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$21.82 |
| Rate for Payer: Aetna Commercial |
$17.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.73
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Cigna Commercial |
$18.87
|
| Rate for Payer: First Health Commercial |
$21.59
|
| Rate for Payer: Humana Commercial |
$19.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.00
|
| Rate for Payer: Ohio Health Group HMO |
$17.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.68
|
| Rate for Payer: PHCS Commercial |
$21.82
|
| Rate for Payer: United Healthcare All Payer |
$20.00
|
|
|
VALCYTE 450 MG TABLET
|
Facility
|
OP
|
$22.73
|
|
|
Service Code
|
NDC 31722083260
|
| Hospital Charge Code |
25001641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$21.82 |
| Rate for Payer: Aetna Commercial |
$17.50
|
| Rate for Payer: Anthem Medicaid |
$7.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.73
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Cigna Commercial |
$18.87
|
| Rate for Payer: First Health Commercial |
$21.59
|
| Rate for Payer: Humana Commercial |
$19.32
|
| Rate for Payer: Humana KY Medicaid |
$7.82
|
| Rate for Payer: Kentucky WC Medicaid |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.00
|
| Rate for Payer: Ohio Health Group HMO |
$17.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.68
|
| Rate for Payer: PHCS Commercial |
$21.82
|
| Rate for Payer: United Healthcare All Payer |
$20.00
|
|
