|
GASTRE PARTIAL - DISL; GASTRO
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 43632
|
| Hospital Charge Code |
76101785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$928.88 |
| Max. Negotiated Rate |
$2,832.92 |
| Rate for Payer: Aetna Commercial |
$2,832.92
|
| Rate for Payer: Ambetter Exchange |
$1,940.17
|
| Rate for Payer: Anthem Medicaid |
$928.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,940.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,940.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,328.20
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,563.49
|
| Rate for Payer: Healthspan PPO |
$2,389.05
|
| Rate for Payer: Humana Medicaid |
$928.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,584.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,940.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,940.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$947.46
|
| Rate for Payer: Molina Healthcare Passport |
$928.88
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,522.22
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$938.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,940.17
|
|
|
GASTRE PARTIAL - DISL; GASTRO
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 43632
|
| Hospital Charge Code |
76101785
|
|
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
|
|
|
GASTRE PARTIAL - DISL; GASTRO
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 43632
|
| Hospital Charge Code |
76101785
|
|
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
|
|
|
GASTRE PARTIAL - DISL; GASTR(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 43632
|
| Hospital Charge Code |
761P1785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$928.88 |
| Max. Negotiated Rate |
$2,832.92 |
| Rate for Payer: Aetna Commercial |
$2,832.92
|
| Rate for Payer: Ambetter Exchange |
$1,940.17
|
| Rate for Payer: Anthem Medicaid |
$928.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,940.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,940.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,328.20
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,563.49
|
| Rate for Payer: Healthspan PPO |
$2,389.05
|
| Rate for Payer: Humana Medicaid |
$928.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,584.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,940.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,940.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$947.46
|
| Rate for Payer: Molina Healthcare Passport |
$928.88
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,522.22
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$938.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,940.17
|
|
|
GASTRIC EMPTYING IMAG STUDY
|
Facility
|
IP
|
$2,020.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
34000011
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$606.00 |
| Max. Negotiated Rate |
$1,939.20 |
| Rate for Payer: Aetna Commercial |
$1,555.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,575.60
|
| Rate for Payer: Cash Price |
$1,010.00
|
| Rate for Payer: Cigna Commercial |
$1,676.60
|
| Rate for Payer: First Health Commercial |
$1,919.00
|
| Rate for Payer: Humana Commercial |
$1,717.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,656.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,490.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$606.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,777.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,515.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,616.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,393.80
|
| Rate for Payer: PHCS Commercial |
$1,939.20
|
| Rate for Payer: United Healthcare All Payer |
$1,777.60
|
|
|
GASTRIC EMPTYING IMAG STUDY
|
Facility
|
OP
|
$2,020.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
34000011
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,939.20 |
| Rate for Payer: Aetna Commercial |
$1,555.40
|
| Rate for Payer: Anthem Medicaid |
$694.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,575.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$1,010.00
|
| Rate for Payer: Cash Price |
$1,010.00
|
| Rate for Payer: Cigna Commercial |
$1,676.60
|
| Rate for Payer: First Health Commercial |
$1,919.00
|
| Rate for Payer: Humana Commercial |
$1,717.00
|
| Rate for Payer: Humana KY Medicaid |
$694.68
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$701.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,656.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,490.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$708.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,777.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,515.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,616.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,393.80
|
| Rate for Payer: PHCS Commercial |
$1,939.20
|
| Rate for Payer: United Healthcare All Payer |
$1,777.60
|
|
|
GASTRIC EMPTYING IMAG STUDY
|
Professional
|
Both
|
$2,020.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
34000011
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$43.45 |
| Max. Negotiated Rate |
$1,212.00 |
| Rate for Payer: Aetna Commercial |
$407.49
|
| Rate for Payer: Ambetter Exchange |
$264.30
|
| Rate for Payer: Anthem Medicaid |
$145.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$264.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$264.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$317.16
|
| Rate for Payer: Cash Price |
$1,010.00
|
| Rate for Payer: Cash Price |
$1,010.00
|
| Rate for Payer: Cigna Commercial |
$330.10
|
| Rate for Payer: Healthspan PPO |
$407.28
|
| Rate for Payer: Humana Medicaid |
$145.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$264.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$148.14
|
| Rate for Payer: Molina Healthcare Passport |
$145.24
|
| Rate for Payer: Multiplan PHCS |
$1,212.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$343.59
|
| Rate for Payer: UHCCP Medicaid |
$707.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$264.30
|
|
|
GASTRIC EMPTYING IMAG STUDY(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
340P0011
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$43.45 |
| Max. Negotiated Rate |
$407.49 |
| Rate for Payer: Aetna Commercial |
$407.49
|
| Rate for Payer: Ambetter Exchange |
$264.30
|
| Rate for Payer: Anthem Medicaid |
$145.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$264.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$264.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$317.16
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$330.10
|
| Rate for Payer: Healthspan PPO |
$407.28
|
| Rate for Payer: Humana Medicaid |
$145.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$264.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$148.14
|
| Rate for Payer: Molina Healthcare Passport |
$145.24
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$343.59
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$264.30
|
|
|
GASTRIC EMPTYING IMAG STUDY(T
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
340T0011
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
GASTRIC EMPTYING IMAG STUDY(T
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
340T0011
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
GASTRIC INTUB&ASPIRA LAVAGE
|
Facility
|
OP
|
$373.00
|
|
|
Service Code
|
HCPCS 43753
|
| Hospital Charge Code |
76101791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$128.27 |
| Max. Negotiated Rate |
$402.82 |
| Rate for Payer: Aetna Commercial |
$287.21
|
| Rate for Payer: Anthem Medicaid |
$128.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$309.59
|
| Rate for Payer: First Health Commercial |
$354.35
|
| Rate for Payer: Humana Commercial |
$317.05
|
| Rate for Payer: Humana KY Medicaid |
$128.27
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$129.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$275.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$328.24
|
| Rate for Payer: Ohio Health Group HMO |
$279.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$298.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$324.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$257.37
|
| Rate for Payer: PHCS Commercial |
$358.08
|
| Rate for Payer: United Healthcare All Payer |
$328.24
|
|
|
GASTRIC INTUB&ASPIRA LAVAGE
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
HCPCS 43753
|
| Hospital Charge Code |
45000266
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$118.20 |
| Max. Negotiated Rate |
$378.24 |
| Rate for Payer: Aetna Commercial |
$303.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.32
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$327.02
|
| Rate for Payer: First Health Commercial |
$374.30
|
| Rate for Payer: Humana Commercial |
$334.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.72
|
| Rate for Payer: Ohio Health Group HMO |
$295.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.86
|
| Rate for Payer: PHCS Commercial |
$378.24
|
| Rate for Payer: United Healthcare All Payer |
$346.72
|
|
|
GASTRIC INTUB&ASPIRA LAVAGE
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
HCPCS 43753
|
| Hospital Charge Code |
45000266
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$135.50 |
| Max. Negotiated Rate |
$402.82 |
| Rate for Payer: Aetna Commercial |
$303.38
|
| Rate for Payer: Anthem Medicaid |
$135.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$327.02
|
| Rate for Payer: First Health Commercial |
$374.30
|
| Rate for Payer: Humana Commercial |
$334.90
|
| Rate for Payer: Humana KY Medicaid |
$135.50
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$136.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$138.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.72
|
| Rate for Payer: Ohio Health Group HMO |
$295.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.86
|
| Rate for Payer: PHCS Commercial |
$378.24
|
| Rate for Payer: United Healthcare All Payer |
$346.72
|
|
|
GASTRIC INTUB&ASPIRA LAVAGE
|
Facility
|
IP
|
$373.00
|
|
|
Service Code
|
HCPCS 43753
|
| Hospital Charge Code |
76101791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.90 |
| Max. Negotiated Rate |
$358.08 |
| Rate for Payer: Aetna Commercial |
$287.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.94
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$309.59
|
| Rate for Payer: First Health Commercial |
$354.35
|
| Rate for Payer: Humana Commercial |
$317.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$275.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$328.24
|
| Rate for Payer: Ohio Health Group HMO |
$279.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$298.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$324.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$257.37
|
| Rate for Payer: PHCS Commercial |
$358.08
|
| Rate for Payer: United Healthcare All Payer |
$328.24
|
|
|
GASTRIC OCCULT BLOOD
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 82271
|
| Hospital Charge Code |
30000251
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$47.04 |
| Rate for Payer: Aetna Commercial |
$37.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.35
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$40.67
|
| Rate for Payer: First Health Commercial |
$46.55
|
| Rate for Payer: Humana Commercial |
$41.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$40.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$43.12
|
| Rate for Payer: Ohio Health Group HMO |
$36.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.81
|
| Rate for Payer: PHCS Commercial |
$47.04
|
| Rate for Payer: United Healthcare All Payer |
$43.12
|
|
|
GASTRIC OCCULT BLOOD
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 82271
|
| Hospital Charge Code |
30000251
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$47.04 |
| Rate for Payer: Aetna Commercial |
$37.73
|
| Rate for Payer: Anthem Medicaid |
$5.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cigna Commercial |
$40.67
|
| Rate for Payer: First Health Commercial |
$46.55
|
| Rate for Payer: Humana Commercial |
$41.65
|
| Rate for Payer: Humana KY Medicaid |
$5.32
|
| Rate for Payer: Humana Medicare Advantage |
$5.32
|
| Rate for Payer: Kentucky WC Medicaid |
$5.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$40.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$43.12
|
| Rate for Payer: Ohio Health Group HMO |
$36.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.81
|
| Rate for Payer: PHCS Commercial |
$47.04
|
| Rate for Payer: United Healthcare All Payer |
$43.12
|
|
|
GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)
|
Facility
|
OP
|
$4,197.13
|
|
|
Service Code
|
CPT 27687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,997.95 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
|
|
GASTROCNEMIUS RECESS (STRAYER)
|
Professional
|
Both
|
$1,301.00
|
|
|
Service Code
|
HCPCS 27687
|
| Hospital Charge Code |
76102648
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$336.01 |
| Max. Negotiated Rate |
$780.60 |
| Rate for Payer: Aetna Commercial |
$686.42
|
| Rate for Payer: Ambetter Exchange |
$432.57
|
| Rate for Payer: Anthem Medicaid |
$336.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$432.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$432.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$519.08
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cigna Commercial |
$761.65
|
| Rate for Payer: Healthspan PPO |
$621.75
|
| Rate for Payer: Humana Medicaid |
$336.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$567.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$432.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$432.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$342.73
|
| Rate for Payer: Molina Healthcare Passport |
$336.01
|
| Rate for Payer: Multiplan PHCS |
$780.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$562.34
|
| Rate for Payer: UHCCP Medicaid |
$455.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$339.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$432.57
|
|
|
GASTROCUTANEOUS FISTULECTOMY
|
Facility
|
OP
|
$1,845.00
|
|
|
Service Code
|
HCPCS 43999
|
| Hospital Charge Code |
76102900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$634.50 |
| Max. Negotiated Rate |
$1,771.20 |
| Rate for Payer: Aetna Commercial |
$1,420.65
|
| Rate for Payer: Anthem Medicaid |
$634.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$866.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,439.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,212.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,169.49
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cigna Commercial |
$1,531.35
|
| Rate for Payer: First Health Commercial |
$1,752.75
|
| Rate for Payer: Humana Commercial |
$1,568.25
|
| Rate for Payer: Humana KY Medicaid |
$634.50
|
| Rate for Payer: Humana Medicare Advantage |
$866.29
|
| Rate for Payer: Kentucky WC Medicaid |
$640.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,512.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,361.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$647.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,623.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,383.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,605.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,273.05
|
| Rate for Payer: PHCS Commercial |
$1,771.20
|
| Rate for Payer: United Healthcare All Payer |
$1,623.60
|
|
|
GASTROCUTANEOUS FISTULECTOMY
|
Professional
|
Both
|
$1,845.00
|
|
|
Service Code
|
HCPCS 43999
|
| Hospital Charge Code |
76102900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,291.50 |
| Rate for Payer: Anthem Medicaid |
$100.00
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$100.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.00
|
| Rate for Payer: Molina Healthcare Passport |
$100.00
|
| Rate for Payer: Multiplan PHCS |
$1,107.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,291.50
|
| Rate for Payer: UHCCP Medicaid |
$645.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.00
|
|
|
GASTROCUTANEOUS FISTULECTOMY
|
Facility
|
IP
|
$1,845.00
|
|
|
Service Code
|
HCPCS 43999
|
| Hospital Charge Code |
76102900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$553.50 |
| Max. Negotiated Rate |
$1,771.20 |
| Rate for Payer: Aetna Commercial |
$1,420.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,439.10
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cigna Commercial |
$1,531.35
|
| Rate for Payer: First Health Commercial |
$1,752.75
|
| Rate for Payer: Humana Commercial |
$1,568.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,512.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,361.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$553.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,623.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,383.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,605.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,273.05
|
| Rate for Payer: PHCS Commercial |
$1,771.20
|
| Rate for Payer: United Healthcare All Payer |
$1,623.60
|
|
|
GASTROGRAFIN 66-10 1ML(30ML)
|
Facility
|
OP
|
$138.58
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
25004218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.57 |
| Max. Negotiated Rate |
$133.04 |
| Rate for Payer: Aetna Commercial |
$106.71
|
| Rate for Payer: Anthem Medicaid |
$47.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.09
|
| Rate for Payer: Cash Price |
$69.29
|
| Rate for Payer: Cigna Commercial |
$115.02
|
| Rate for Payer: First Health Commercial |
$131.65
|
| Rate for Payer: Humana Commercial |
$117.79
|
| Rate for Payer: Humana KY Medicaid |
$47.66
|
| Rate for Payer: Kentucky WC Medicaid |
$48.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$102.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$48.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.95
|
| Rate for Payer: Ohio Health Group HMO |
$103.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.62
|
| Rate for Payer: PHCS Commercial |
$133.04
|
| Rate for Payer: United Healthcare All Payer |
$121.95
|
|
|
GASTROGRAFIN 66-10 1ML(30ML)
|
Facility
|
IP
|
$138.58
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
25004218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.57 |
| Max. Negotiated Rate |
$133.04 |
| Rate for Payer: Aetna Commercial |
$106.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.09
|
| Rate for Payer: Cash Price |
$69.29
|
| Rate for Payer: Cigna Commercial |
$115.02
|
| Rate for Payer: First Health Commercial |
$131.65
|
| Rate for Payer: Humana Commercial |
$117.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$102.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.95
|
| Rate for Payer: Ohio Health Group HMO |
$103.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.62
|
| Rate for Payer: PHCS Commercial |
$133.04
|
| Rate for Payer: United Healthcare All Payer |
$121.95
|
|
|
GASTROGRAFIN 66-10 SOLT 120MLV
|
Facility
|
IP
|
$528.52
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
25003814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.56 |
| Max. Negotiated Rate |
$507.38 |
| Rate for Payer: Aetna Commercial |
$406.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.25
|
| Rate for Payer: Cash Price |
$264.26
|
| Rate for Payer: Cigna Commercial |
$438.67
|
| Rate for Payer: First Health Commercial |
$502.09
|
| Rate for Payer: Humana Commercial |
$449.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.10
|
| Rate for Payer: Ohio Health Group HMO |
$396.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$422.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.68
|
| Rate for Payer: PHCS Commercial |
$507.38
|
| Rate for Payer: United Healthcare All Payer |
$465.10
|
|
|
GASTROGRAFIN 66-10 SOLT 120MLV
|
Facility
|
OP
|
$528.52
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
25003814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.56 |
| Max. Negotiated Rate |
$507.38 |
| Rate for Payer: Aetna Commercial |
$406.96
|
| Rate for Payer: Anthem Medicaid |
$181.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.25
|
| Rate for Payer: Cash Price |
$264.26
|
| Rate for Payer: Cigna Commercial |
$438.67
|
| Rate for Payer: First Health Commercial |
$502.09
|
| Rate for Payer: Humana Commercial |
$449.24
|
| Rate for Payer: Humana KY Medicaid |
$181.76
|
| Rate for Payer: Kentucky WC Medicaid |
$183.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.10
|
| Rate for Payer: Ohio Health Group HMO |
$396.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$422.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.68
|
| Rate for Payer: PHCS Commercial |
$507.38
|
| Rate for Payer: United Healthcare All Payer |
$465.10
|
|
