|
GASTRO JEGUNAL KIT
|
Facility
|
OP
|
$1,956.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$586.99 |
| Max. Negotiated Rate |
$1,878.37 |
| Rate for Payer: Aetna Commercial |
$1,506.61
|
| Rate for Payer: Anthem Medicaid |
$672.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,526.18
|
| Rate for Payer: Cash Price |
$978.32
|
| Rate for Payer: Cigna Commercial |
$1,624.01
|
| Rate for Payer: First Health Commercial |
$1,858.81
|
| Rate for Payer: Humana Commercial |
$1,663.14
|
| Rate for Payer: Humana KY Medicaid |
$672.89
|
| Rate for Payer: Kentucky WC Medicaid |
$679.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,604.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,444.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$586.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$686.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,721.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,467.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,565.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,702.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,350.08
|
| Rate for Payer: PHCS Commercial |
$1,878.37
|
| Rate for Payer: United Healthcare All Payer |
$1,721.84
|
|
|
GASTRO JEGUNAL KIT
|
Facility
|
IP
|
$1,956.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$586.99 |
| Max. Negotiated Rate |
$1,878.37 |
| Rate for Payer: Aetna Commercial |
$1,506.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,526.18
|
| Rate for Payer: Cash Price |
$978.32
|
| Rate for Payer: Cigna Commercial |
$1,624.01
|
| Rate for Payer: First Health Commercial |
$1,858.81
|
| Rate for Payer: Humana Commercial |
$1,663.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,604.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,444.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$586.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,721.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,467.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,565.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,702.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,350.08
|
| Rate for Payer: PHCS Commercial |
$1,878.37
|
| Rate for Payer: United Healthcare All Payer |
$1,721.84
|
|
|
GASTROSTOMY, OPEN; WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,453.89
|
|
|
Service Code
|
CPT 43830
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,752.78 |
| Max. Negotiated Rate |
$2,453.89 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,752.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,453.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,366.25
|
| Rate for Payer: Humana Medicare Advantage |
$1,752.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,103.34
|
|
|
GASTROSTOMY OPEN WO GASTRCTUBE
|
Facility
|
OP
|
$1,810.00
|
|
|
Service Code
|
HCPCS 43830
|
| Hospital Charge Code |
76101797
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$622.46 |
| Max. Negotiated Rate |
$2,453.89 |
| Rate for Payer: Aetna Commercial |
$1,393.70
|
| Rate for Payer: Anthem Medicaid |
$622.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,752.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,453.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,366.25
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$1,502.30
|
| Rate for Payer: First Health Commercial |
$1,719.50
|
| Rate for Payer: Humana Commercial |
$1,538.50
|
| Rate for Payer: Humana KY Medicaid |
$622.46
|
| Rate for Payer: Humana Medicare Advantage |
$1,752.78
|
| Rate for Payer: Kentucky WC Medicaid |
$628.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,103.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,574.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.90
|
| Rate for Payer: PHCS Commercial |
$1,737.60
|
| Rate for Payer: United Healthcare All Payer |
$1,592.80
|
|
|
GASTROSTOMY OPEN WO GASTRCTUBE
|
Facility
|
IP
|
$1,810.00
|
|
|
Service Code
|
HCPCS 43830
|
| Hospital Charge Code |
76101797
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$543.00 |
| Max. Negotiated Rate |
$1,737.60 |
| Rate for Payer: Aetna Commercial |
$1,393.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.80
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$1,502.30
|
| Rate for Payer: First Health Commercial |
$1,719.50
|
| Rate for Payer: Humana Commercial |
$1,538.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,574.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.90
|
| Rate for Payer: PHCS Commercial |
$1,737.60
|
| Rate for Payer: United Healthcare All Payer |
$1,592.80
|
|
|
GASTROSTOMY OPEN WO GASTRCTUBE
|
Professional
|
Both
|
$1,810.00
|
|
|
Service Code
|
HCPCS 43830
|
| Hospital Charge Code |
76101797
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$336.97 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna Commercial |
$988.43
|
| Rate for Payer: Ambetter Exchange |
$669.02
|
| Rate for Payer: Anthem Medicaid |
$336.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$669.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$669.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$802.82
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$913.61
|
| Rate for Payer: Healthspan PPO |
$833.56
|
| Rate for Payer: Humana Medicaid |
$336.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$882.80
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$669.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$669.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$343.71
|
| Rate for Payer: Molina Healthcare Passport |
$336.97
|
| Rate for Payer: Multiplan PHCS |
$1,086.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$869.73
|
| Rate for Payer: UHCCP Medicaid |
$633.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$340.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$669.02
|
|
|
GASTROSTOMY OPEN WO GASTRCTUBE
|
Professional
|
Both
|
$1,810.00
|
|
|
Service Code
|
HCPCS 43830
|
| Hospital Charge Code |
761P1797
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$336.97 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna Commercial |
$988.43
|
| Rate for Payer: Ambetter Exchange |
$669.02
|
| Rate for Payer: Anthem Medicaid |
$336.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$669.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$669.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$802.82
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$913.61
|
| Rate for Payer: Healthspan PPO |
$833.56
|
| Rate for Payer: Humana Medicaid |
$336.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$882.80
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$669.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$669.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$343.71
|
| Rate for Payer: Molina Healthcare Passport |
$336.97
|
| Rate for Payer: Multiplan PHCS |
$1,086.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$869.73
|
| Rate for Payer: UHCCP Medicaid |
$633.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$340.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$669.02
|
|
|
GASTROTOMY REMV FOREIGN BODY
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 43500
|
| Hospital Charge Code |
76101779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
GASTROTOMY REMV FOREIGN BODY
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 43500
|
| Hospital Charge Code |
76101779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.59 |
| Max. Negotiated Rate |
$1,121.69 |
| Rate for Payer: Aetna Commercial |
$1,121.69
|
| Rate for Payer: Ambetter Exchange |
$752.35
|
| Rate for Payer: Anthem Medicaid |
$416.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$752.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$752.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$902.82
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,034.93
|
| Rate for Payer: Healthspan PPO |
$945.95
|
| Rate for Payer: Humana Medicaid |
$416.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,000.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$752.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$752.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$424.92
|
| Rate for Payer: Molina Healthcare Passport |
$416.59
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$978.05
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$420.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$752.35
|
|
|
GASTROTOMY REMV FOREIGN BODY
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 43500
|
| Hospital Charge Code |
76101779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
GASTROTOMY REMV FOREIGN BODY(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 43500
|
| Hospital Charge Code |
761P1779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.59 |
| Max. Negotiated Rate |
$1,121.69 |
| Rate for Payer: Aetna Commercial |
$1,121.69
|
| Rate for Payer: Ambetter Exchange |
$752.35
|
| Rate for Payer: Anthem Medicaid |
$416.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$752.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$752.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$902.82
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,034.93
|
| Rate for Payer: Healthspan PPO |
$945.95
|
| Rate for Payer: Humana Medicaid |
$416.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,000.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$752.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$752.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$424.92
|
| Rate for Payer: Molina Healthcare Passport |
$416.59
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$978.05
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$420.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$752.35
|
|
|
GASTROTOMY ULCER REPR
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 43501
|
| Hospital Charge Code |
76101780
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$630.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem Medicaid |
$722.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Humana KY Medicaid |
$722.19
|
| Rate for Payer: Kentucky WC Medicaid |
$729.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$736.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,827.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
GASTROTOMY ULCER REPR
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 43501
|
| Hospital Charge Code |
76101780
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$630.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,827.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
GASTROTOMY ULCER REPR
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 43501
|
| Hospital Charge Code |
76101780
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$681.01 |
| Max. Negotiated Rate |
$1,936.48 |
| Rate for Payer: Aetna Commercial |
$1,936.48
|
| Rate for Payer: Ambetter Exchange |
$1,282.98
|
| Rate for Payer: Anthem Medicaid |
$681.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,282.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,282.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,539.58
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,798.86
|
| Rate for Payer: Healthspan PPO |
$1,633.07
|
| Rate for Payer: Humana Medicaid |
$681.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,716.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,282.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,282.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$694.63
|
| Rate for Payer: Molina Healthcare Passport |
$681.01
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,667.87
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$687.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,282.98
|
|
|
GASTROTOMY ULCER REPR(P
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 43501
|
| Hospital Charge Code |
761P1780
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$681.01 |
| Max. Negotiated Rate |
$1,936.48 |
| Rate for Payer: Aetna Commercial |
$1,936.48
|
| Rate for Payer: Ambetter Exchange |
$1,282.98
|
| Rate for Payer: Anthem Medicaid |
$681.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,282.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,282.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,539.58
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,798.86
|
| Rate for Payer: Healthspan PPO |
$1,633.07
|
| Rate for Payer: Humana Medicaid |
$681.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,716.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,282.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,282.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$694.63
|
| Rate for Payer: Molina Healthcare Passport |
$681.01
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,667.87
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$687.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,282.98
|
|
|
GATED HEART PLANAR SINGLE
|
Facility
|
IP
|
$1,792.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
34000020
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$537.60 |
| Max. Negotiated Rate |
$1,720.32 |
| Rate for Payer: Aetna Commercial |
$1,379.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.76
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: Cigna Commercial |
$1,487.36
|
| Rate for Payer: First Health Commercial |
$1,702.40
|
| Rate for Payer: Humana Commercial |
$1,523.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,469.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,322.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$537.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,576.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,559.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,236.48
|
| Rate for Payer: PHCS Commercial |
$1,720.32
|
| Rate for Payer: United Healthcare All Payer |
$1,576.96
|
|
|
GATED HEART PLANAR SINGLE
|
Facility
|
OP
|
$1,792.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
34000020
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,720.32 |
| Rate for Payer: Aetna Commercial |
$1,379.84
|
| Rate for Payer: Anthem Medicaid |
$616.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: Cigna Commercial |
$1,487.36
|
| Rate for Payer: First Health Commercial |
$1,702.40
|
| Rate for Payer: Humana Commercial |
$1,523.20
|
| Rate for Payer: Humana KY Medicaid |
$616.27
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$622.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,469.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,322.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$628.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,576.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,559.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,236.48
|
| Rate for Payer: PHCS Commercial |
$1,720.32
|
| Rate for Payer: United Healthcare All Payer |
$1,576.96
|
|
|
GATED HEART PLANAR SINGLE
|
Professional
|
Both
|
$1,792.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
34000020
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$55.59 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$396.01
|
| Rate for Payer: Ambetter Exchange |
$185.54
|
| Rate for Payer: Anthem Medicaid |
$191.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$185.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$185.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.65
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: Cigna Commercial |
$394.92
|
| Rate for Payer: Healthspan PPO |
$395.81
|
| Rate for Payer: Humana Medicaid |
$191.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$185.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.17
|
| Rate for Payer: Molina Healthcare Passport |
$191.34
|
| Rate for Payer: Multiplan PHCS |
$1,075.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.20
|
| Rate for Payer: UHCCP Medicaid |
$627.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$185.54
|
|
|
GATED HEART PLANAR SINGLE(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
340P0020
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$55.59 |
| Max. Negotiated Rate |
$396.01 |
| Rate for Payer: Aetna Commercial |
$396.01
|
| Rate for Payer: Ambetter Exchange |
$185.54
|
| Rate for Payer: Anthem Medicaid |
$191.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$185.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$185.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.65
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$394.92
|
| Rate for Payer: Healthspan PPO |
$395.81
|
| Rate for Payer: Humana Medicaid |
$191.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$185.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.17
|
| Rate for Payer: Molina Healthcare Passport |
$191.34
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.20
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$185.54
|
|
|
GATED HEART PLANAR SINGLE(T
|
Facility
|
OP
|
$1,617.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
340T0020
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,552.32 |
| Rate for Payer: Aetna Commercial |
$1,245.09
|
| Rate for Payer: Anthem Medicaid |
$556.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,261.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$1,342.11
|
| Rate for Payer: First Health Commercial |
$1,536.15
|
| Rate for Payer: Humana Commercial |
$1,374.45
|
| Rate for Payer: Humana KY Medicaid |
$556.09
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$561.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,325.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,193.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$567.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,422.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,212.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,293.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,406.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,115.73
|
| Rate for Payer: PHCS Commercial |
$1,552.32
|
| Rate for Payer: United Healthcare All Payer |
$1,422.96
|
|
|
GATED HEART PLANAR SINGLE(T
|
Facility
|
IP
|
$1,617.00
|
|
|
Service Code
|
HCPCS 78472
|
| Hospital Charge Code |
340T0020
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$485.10 |
| Max. Negotiated Rate |
$1,552.32 |
| Rate for Payer: Aetna Commercial |
$1,245.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,261.26
|
| Rate for Payer: Cash Price |
$808.50
|
| Rate for Payer: Cigna Commercial |
$1,342.11
|
| Rate for Payer: First Health Commercial |
$1,536.15
|
| Rate for Payer: Humana Commercial |
$1,374.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,325.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,193.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$485.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,422.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,212.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,293.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,406.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,115.73
|
| Rate for Payer: PHCS Commercial |
$1,552.32
|
| Rate for Payer: United Healthcare All Payer |
$1,422.96
|
|
|
GAVISCON (COMBINATION) CH 1TAB
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 904536560
|
| Hospital Charge Code |
25000713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
GAVISCON (COMBINATION) CH 1TAB
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 904536560
|
| Hospital Charge Code |
25000713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
GAZYVA 10MG [1000 MG VL]
|
Facility
|
IP
|
$46,939.32
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
25002667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,081.80 |
| Max. Negotiated Rate |
$45,061.75 |
| Rate for Payer: Aetna Commercial |
$36,143.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36,612.67
|
| Rate for Payer: Cash Price |
$23,469.66
|
| Rate for Payer: Cigna Commercial |
$38,959.64
|
| Rate for Payer: First Health Commercial |
$44,592.35
|
| Rate for Payer: Humana Commercial |
$39,898.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38,490.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$34,641.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14,081.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$41,306.60
|
| Rate for Payer: Ohio Health Group HMO |
$35,204.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37,551.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$40,837.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32,388.13
|
| Rate for Payer: PHCS Commercial |
$45,061.75
|
| Rate for Payer: United Healthcare All Payer |
$41,306.60
|
|
|
GAZYVA 10MG [1000 MG VL]
|
Facility
|
OP
|
$46,939.32
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
25002667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.46 |
| Max. Negotiated Rate |
$45,061.75 |
| Rate for Payer: Aetna Commercial |
$36,143.28
|
| Rate for Payer: Anthem Medicaid |
$16,142.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36,612.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$109.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.92
|
| Rate for Payer: Cash Price |
$23,469.66
|
| Rate for Payer: Cash Price |
$23,469.66
|
| Rate for Payer: Cigna Commercial |
$38,959.64
|
| Rate for Payer: First Health Commercial |
$44,592.35
|
| Rate for Payer: Humana Commercial |
$39,898.42
|
| Rate for Payer: Humana KY Medicaid |
$16,142.43
|
| Rate for Payer: Humana Medicare Advantage |
$78.46
|
| Rate for Payer: Kentucky WC Medicaid |
$16,306.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38,490.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$34,641.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,466.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$41,306.60
|
| Rate for Payer: Ohio Health Group HMO |
$35,204.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37,551.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$40,837.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32,388.13
|
| Rate for Payer: PHCS Commercial |
$45,061.75
|
| Rate for Payer: United Healthcare All Payer |
$41,306.60
|
|
