|
GSTRRRHPHY SUT DUOD/GASTRC ULC
|
Professional
|
Both
|
$1,875.00
|
|
|
Service Code
|
HCPCS 43840
|
| Hospital Charge Code |
76101798
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$557.26 |
| Max. Negotiated Rate |
$1,890.12 |
| Rate for Payer: Aetna Commercial |
$1,890.12
|
| Rate for Payer: Anthem Medicaid |
$557.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,875.00
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,715.52
|
| Rate for Payer: Healthspan PPO |
$1,593.97
|
| Rate for Payer: Humana Medicaid |
$557.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,722.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$568.41
|
| Rate for Payer: Molina Healthcare Passport |
$557.26
|
| Rate for Payer: Multiplan PHCS |
$1,125.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,312.50
|
| Rate for Payer: UHCCP Medicaid |
$656.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$562.83
|
|
|
GTR SHORT W CABLES 23*53
|
Facility
|
IP
|
$11,390.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,480.76 |
| Max. Negotiated Rate |
$10,934.82 |
| Rate for Payer: Aetna Commercial |
$8,770.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,884.54
|
| Rate for Payer: Cash Price |
$5,695.22
|
| Rate for Payer: Cigna Commercial |
$9,454.07
|
| Rate for Payer: First Health Commercial |
$10,820.92
|
| Rate for Payer: Humana Commercial |
$9,681.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,340.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,406.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,417.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,023.59
|
| Rate for Payer: Ohio Health Group HMO |
$8,542.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,278.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,480.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,531.04
|
| Rate for Payer: PHCS Commercial |
$10,934.82
|
| Rate for Payer: United Healthcare All Payer |
$10,023.59
|
|
|
GTR SHORT W CABLES 23*53
|
Facility
|
OP
|
$11,390.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,480.76 |
| Max. Negotiated Rate |
$10,934.82 |
| Rate for Payer: Aetna Commercial |
$8,770.64
|
| Rate for Payer: Anthem Medicaid |
$3,917.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,884.54
|
| Rate for Payer: Cash Price |
$5,695.22
|
| Rate for Payer: Cigna Commercial |
$9,454.07
|
| Rate for Payer: First Health Commercial |
$10,820.92
|
| Rate for Payer: Humana Commercial |
$9,681.87
|
| Rate for Payer: Humana KY Medicaid |
$3,917.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3,957.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,340.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,406.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,417.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,995.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,023.59
|
| Rate for Payer: Ohio Health Group HMO |
$8,542.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,278.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,480.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,531.04
|
| Rate for Payer: PHCS Commercial |
$10,934.82
|
| Rate for Payer: United Healthcare All Payer |
$10,023.59
|
|
|
G TUBE CHANGE
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
76101793
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$134.55 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna Commercial |
$796.95
|
| Rate for Payer: Anthem Medicaid |
$355.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$807.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$859.05
|
| Rate for Payer: First Health Commercial |
$983.25
|
| Rate for Payer: Humana Commercial |
$879.75
|
| Rate for Payer: Humana KY Medicaid |
$355.94
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$359.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$363.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$910.80
|
| Rate for Payer: Ohio Health Group HMO |
$776.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$207.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$320.85
|
| Rate for Payer: PHCS Commercial |
$993.60
|
| Rate for Payer: United Healthcare All Payer |
$910.80
|
|
|
G TUBE CHANGE
|
Professional
|
Both
|
$1,035.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
76101793
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$1,035.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.89
|
| Rate for Payer: Anthem Medicaid |
$30.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,035.00
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$350.08
|
| Rate for Payer: Humana Medicaid |
$30.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$31.55
|
| Rate for Payer: Molina Healthcare Passport |
$30.93
|
| Rate for Payer: Multiplan PHCS |
$621.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$724.50
|
| Rate for Payer: UHCCP Medicaid |
$32.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$31.24
|
|
|
G TUBE CHANGE
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
45000267
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$47.45 |
| Max. Negotiated Rate |
$350.40 |
| Rate for Payer: Aetna Commercial |
$281.05
|
| Rate for Payer: Anthem Medicaid |
$125.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$284.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$182.50
|
| Rate for Payer: Cash Price |
$182.50
|
| Rate for Payer: Cigna Commercial |
$302.95
|
| Rate for Payer: First Health Commercial |
$346.75
|
| Rate for Payer: Humana Commercial |
$310.25
|
| Rate for Payer: Humana KY Medicaid |
$125.52
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$126.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$299.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$269.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$128.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$321.20
|
| Rate for Payer: Ohio Health Group HMO |
$273.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.15
|
| Rate for Payer: PHCS Commercial |
$350.40
|
| Rate for Payer: United Healthcare All Payer |
$321.20
|
|
|
G TUBE CHANGE
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
45000267
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$47.45 |
| Max. Negotiated Rate |
$350.40 |
| Rate for Payer: Aetna Commercial |
$281.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$284.70
|
| Rate for Payer: Cash Price |
$182.50
|
| Rate for Payer: Cigna Commercial |
$302.95
|
| Rate for Payer: First Health Commercial |
$346.75
|
| Rate for Payer: Humana Commercial |
$310.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$299.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$269.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$321.20
|
| Rate for Payer: Ohio Health Group HMO |
$273.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.15
|
| Rate for Payer: PHCS Commercial |
$350.40
|
| Rate for Payer: United Healthcare All Payer |
$321.20
|
|
|
G TUBE CHANGE
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
76101793
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$134.55 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna Commercial |
$796.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$807.30
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$859.05
|
| Rate for Payer: First Health Commercial |
$983.25
|
| Rate for Payer: Humana Commercial |
$879.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$310.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$910.80
|
| Rate for Payer: Ohio Health Group HMO |
$776.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$207.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$320.85
|
| Rate for Payer: PHCS Commercial |
$993.60
|
| Rate for Payer: United Healthcare All Payer |
$910.80
|
|
|
G TUBE CHANGE(P
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
761P1793
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$350.08 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.89
|
| Rate for Payer: Anthem Medicaid |
$30.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$240.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$350.08
|
| Rate for Payer: Humana Medicaid |
$30.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$31.55
|
| Rate for Payer: Molina Healthcare Passport |
$30.93
|
| Rate for Payer: Multiplan PHCS |
$144.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$168.00
|
| Rate for Payer: UHCCP Medicaid |
$32.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$31.24
|
|
|
G TUBE CHANGE(T
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
761T1793
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.35 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.45
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
G TUBE CHANGE(T
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
761T1793
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.35 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem Medicaid |
$273.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Humana KY Medicaid |
$273.40
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$276.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.45
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Facility
|
OP
|
$1,522.88
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
761T2007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.97 |
| Max. Negotiated Rate |
$1,461.96 |
| Rate for Payer: Aetna Commercial |
$1,172.62
|
| Rate for Payer: Anthem Medicaid |
$523.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.85
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$761.44
|
| Rate for Payer: Cash Price |
$761.44
|
| Rate for Payer: Cigna Commercial |
$1,263.99
|
| Rate for Payer: First Health Commercial |
$1,446.74
|
| Rate for Payer: Humana Commercial |
$1,294.45
|
| Rate for Payer: Humana KY Medicaid |
$523.72
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$529.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.13
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.09
|
| Rate for Payer: PHCS Commercial |
$1,461.96
|
| Rate for Payer: United Healthcare All Payer |
$1,340.13
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Facility
|
IP
|
$2,517.88
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
76102007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$2,417.16 |
| Rate for Payer: Aetna Commercial |
$1,938.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,963.95
|
| Rate for Payer: Cash Price |
$1,258.94
|
| Rate for Payer: Cigna Commercial |
$2,089.84
|
| Rate for Payer: First Health Commercial |
$2,391.99
|
| Rate for Payer: Humana Commercial |
$2,140.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,064.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,858.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$755.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,215.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,888.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$503.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$327.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$780.54
|
| Rate for Payer: PHCS Commercial |
$2,417.16
|
| Rate for Payer: United Healthcare All Payer |
$2,215.73
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Facility
|
IP
|
$1,522.88
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
761T2007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.97 |
| Max. Negotiated Rate |
$1,461.96 |
| Rate for Payer: Aetna Commercial |
$1,172.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.85
|
| Rate for Payer: Cash Price |
$761.44
|
| Rate for Payer: Cigna Commercial |
$1,263.99
|
| Rate for Payer: First Health Commercial |
$1,446.74
|
| Rate for Payer: Humana Commercial |
$1,294.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.13
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.09
|
| Rate for Payer: PHCS Commercial |
$1,461.96
|
| Rate for Payer: United Healthcare All Payer |
$1,340.13
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Professional
|
Both
|
$995.00
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
761P2007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.78 |
| Max. Negotiated Rate |
$995.00 |
| Rate for Payer: Aetna Commercial |
$109.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$61.49
|
| Rate for Payer: Anthem Medicaid |
$55.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$995.00
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$99.63
|
| Rate for Payer: Healthspan PPO |
$895.64
|
| Rate for Payer: Humana Medicaid |
$55.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.90
|
| Rate for Payer: Molina Healthcare Passport |
$55.78
|
| Rate for Payer: Multiplan PHCS |
$597.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$696.50
|
| Rate for Payer: UHCCP Medicaid |
$64.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.34
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Facility
|
OP
|
$1,174.00
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
45000275
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.62 |
| Max. Negotiated Rate |
$1,127.04 |
| Rate for Payer: Aetna Commercial |
$903.98
|
| Rate for Payer: Anthem Medicaid |
$403.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$915.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$587.00
|
| Rate for Payer: Cash Price |
$587.00
|
| Rate for Payer: Cigna Commercial |
$974.42
|
| Rate for Payer: First Health Commercial |
$1,115.30
|
| Rate for Payer: Humana Commercial |
$997.90
|
| Rate for Payer: Humana KY Medicaid |
$403.74
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$407.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$962.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$866.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$411.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,033.12
|
| Rate for Payer: Ohio Health Group HMO |
$880.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.94
|
| Rate for Payer: PHCS Commercial |
$1,127.04
|
| Rate for Payer: United Healthcare All Payer |
$1,033.12
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Facility
|
OP
|
$2,517.88
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
76102007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$2,417.16 |
| Rate for Payer: Aetna Commercial |
$1,938.77
|
| Rate for Payer: Anthem Medicaid |
$865.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,963.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$1,258.94
|
| Rate for Payer: Cash Price |
$1,258.94
|
| Rate for Payer: Cigna Commercial |
$2,089.84
|
| Rate for Payer: First Health Commercial |
$2,391.99
|
| Rate for Payer: Humana Commercial |
$2,140.20
|
| Rate for Payer: Humana KY Medicaid |
$865.90
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$874.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,064.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,858.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$883.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,215.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,888.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$503.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$327.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$780.54
|
| Rate for Payer: PHCS Commercial |
$2,417.16
|
| Rate for Payer: United Healthcare All Payer |
$2,215.73
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Professional
|
Both
|
$2,517.88
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
76102007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.78 |
| Max. Negotiated Rate |
$2,517.88 |
| Rate for Payer: Aetna Commercial |
$109.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$61.49
|
| Rate for Payer: Anthem Medicaid |
$55.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,517.88
|
| Rate for Payer: Cash Price |
$1,258.94
|
| Rate for Payer: Cash Price |
$1,258.94
|
| Rate for Payer: Cigna Commercial |
$99.63
|
| Rate for Payer: Healthspan PPO |
$895.64
|
| Rate for Payer: Humana Medicaid |
$55.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.90
|
| Rate for Payer: Molina Healthcare Passport |
$55.78
|
| Rate for Payer: Multiplan PHCS |
$1,510.73
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,762.52
|
| Rate for Payer: UHCCP Medicaid |
$64.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.34
|
|
|
GTUBE CHNGE W FLUORO INCLD INJ
|
Facility
|
IP
|
$1,174.00
|
|
|
Service Code
|
HCPCS 49450
|
| Hospital Charge Code |
45000275
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.62 |
| Max. Negotiated Rate |
$1,127.04 |
| Rate for Payer: Aetna Commercial |
$903.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$915.72
|
| Rate for Payer: Cash Price |
$587.00
|
| Rate for Payer: Cigna Commercial |
$974.42
|
| Rate for Payer: First Health Commercial |
$1,115.30
|
| Rate for Payer: Humana Commercial |
$997.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$962.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$866.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,033.12
|
| Rate for Payer: Ohio Health Group HMO |
$880.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.94
|
| Rate for Payer: PHCS Commercial |
$1,127.04
|
| Rate for Payer: United Healthcare All Payer |
$1,033.12
|
|
|
GUAIFENESIN 100mg/5mL UD 5mL
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 121174400
|
| Hospital Charge Code |
25004317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.47
|
| Rate for Payer: Ohio Health Group HMO |
$1.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Payer |
$1.47
|
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.30
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna Commercial |
$1.39
|
| Rate for Payer: First Health Commercial |
$1.59
|
| Rate for Payer: Humana Commercial |
$1.42
|
|
|
GUAIFENESIN 100mg/5mL UD 5mL
|
Facility
|
OP
|
$1.67
|
|
|
Service Code
|
NDC 121174400
|
| Hospital Charge Code |
25004317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna Commercial |
$1.29
|
| Rate for Payer: Anthem Medicaid |
$0.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.30
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna Commercial |
$1.39
|
| Rate for Payer: First Health Commercial |
$1.59
|
| Rate for Payer: Humana Commercial |
$1.42
|
| Rate for Payer: Humana KY Medicaid |
$0.57
|
| Rate for Payer: Kentucky WC Medicaid |
$0.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.47
|
| Rate for Payer: Ohio Health Group HMO |
$1.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Payer |
$1.47
|
|
|
GUARDWIRE 2.5-5.0
|
Facility
|
OP
|
$8,548.75
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.34 |
| Max. Negotiated Rate |
$8,206.80 |
| Rate for Payer: Aetna Commercial |
$6,582.54
|
| Rate for Payer: Anthem Medicaid |
$2,939.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,668.02
|
| Rate for Payer: Cash Price |
$4,274.38
|
| Rate for Payer: Cigna Commercial |
$7,095.46
|
| Rate for Payer: First Health Commercial |
$8,121.31
|
| Rate for Payer: Humana Commercial |
$7,266.44
|
| Rate for Payer: Humana KY Medicaid |
$2,939.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,969.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,009.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,308.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,564.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,998.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,522.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,709.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,111.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,650.11
|
| Rate for Payer: PHCS Commercial |
$8,206.80
|
| Rate for Payer: United Healthcare All Payer |
$7,522.90
|
|
|
GUARDWIRE 2.5-5.0
|
Facility
|
IP
|
$8,548.75
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.34 |
| Max. Negotiated Rate |
$8,206.80 |
| Rate for Payer: Aetna Commercial |
$6,582.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,668.02
|
| Rate for Payer: Cash Price |
$4,274.38
|
| Rate for Payer: Cigna Commercial |
$7,095.46
|
| Rate for Payer: First Health Commercial |
$8,121.31
|
| Rate for Payer: Humana Commercial |
$7,266.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,009.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,308.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,564.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,522.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,709.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,111.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,650.11
|
| Rate for Payer: PHCS Commercial |
$8,206.80
|
| Rate for Payer: United Healthcare All Payer |
$7,522.90
|
|
|
GUARDWIRE 3.0-6.0
|
Facility
|
IP
|
$8,548.75
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.34 |
| Max. Negotiated Rate |
$8,206.80 |
| Rate for Payer: Aetna Commercial |
$6,582.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,668.02
|
| Rate for Payer: Cash Price |
$4,274.38
|
| Rate for Payer: Cigna Commercial |
$7,095.46
|
| Rate for Payer: First Health Commercial |
$8,121.31
|
| Rate for Payer: Humana Commercial |
$7,266.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,009.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,308.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,564.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,522.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,709.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,111.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,650.11
|
| Rate for Payer: PHCS Commercial |
$8,206.80
|
| Rate for Payer: United Healthcare All Payer |
$7,522.90
|
|
|
GUARDWIRE 3.0-6.0
|
Facility
|
OP
|
$8,548.75
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.34 |
| Max. Negotiated Rate |
$8,206.80 |
| Rate for Payer: Aetna Commercial |
$6,582.54
|
| Rate for Payer: Anthem Medicaid |
$2,939.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,668.02
|
| Rate for Payer: Cash Price |
$4,274.38
|
| Rate for Payer: Cigna Commercial |
$7,095.46
|
| Rate for Payer: First Health Commercial |
$8,121.31
|
| Rate for Payer: Humana Commercial |
$7,266.44
|
| Rate for Payer: Humana KY Medicaid |
$2,939.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,969.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,009.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,308.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,564.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,998.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,522.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,709.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,111.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,650.11
|
| Rate for Payer: PHCS Commercial |
$8,206.80
|
| Rate for Payer: United Healthcare All Payer |
$7,522.90
|
|
