|
ESKALITH CR (LITHIU 450MG/1TAB
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 378145001
|
| Hospital Charge Code |
25000635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
ESKALITH CR (LITHIU 450MG/1TAB
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 378145001
|
| Hospital Charge Code |
25000635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
ESMOLOL 10mg (100mg SDV)
|
Facility
|
OP
|
$80.40
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
25002904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$77.18 |
| Rate for Payer: Aetna Commercial |
$61.91
|
| Rate for Payer: Anthem Medicaid |
$27.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.73
|
| Rate for Payer: First Health Commercial |
$76.38
|
| Rate for Payer: Humana Commercial |
$68.34
|
| Rate for Payer: Humana KY Medicaid |
$27.65
|
| Rate for Payer: Humana Medicare Advantage |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$27.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.75
|
| Rate for Payer: Ohio Health Group HMO |
$60.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.92
|
| Rate for Payer: PHCS Commercial |
$77.18
|
| Rate for Payer: United Healthcare All Payer |
$70.75
|
|
|
ESMOLOL 10mg (100mg SDV)
|
Facility
|
IP
|
$80.40
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
25002904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$77.18 |
| Rate for Payer: Aetna Commercial |
$61.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.71
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.73
|
| Rate for Payer: First Health Commercial |
$76.38
|
| Rate for Payer: Humana Commercial |
$68.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.75
|
| Rate for Payer: Ohio Health Group HMO |
$60.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.92
|
| Rate for Payer: PHCS Commercial |
$77.18
|
| Rate for Payer: United Healthcare All Payer |
$70.75
|
|
|
ESMOLOL(GENERIC)10MG(250ML)
|
Facility
|
IP
|
$593.00
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
25002903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.09 |
| Max. Negotiated Rate |
$569.28 |
| Rate for Payer: Aetna Commercial |
$456.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$462.54
|
| Rate for Payer: Cash Price |
$296.50
|
| Rate for Payer: Cigna Commercial |
$492.19
|
| Rate for Payer: First Health Commercial |
$563.35
|
| Rate for Payer: Humana Commercial |
$504.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$486.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$437.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$521.84
|
| Rate for Payer: Ohio Health Group HMO |
$444.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$183.83
|
| Rate for Payer: PHCS Commercial |
$569.28
|
| Rate for Payer: United Healthcare All Payer |
$521.84
|
|
|
ESMOLOL(GENERIC)10MG(250ML)
|
Facility
|
OP
|
$593.00
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
25002903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$569.28 |
| Rate for Payer: Cash Price |
$296.50
|
| Rate for Payer: Cash Price |
$296.50
|
| Rate for Payer: Cigna Commercial |
$492.19
|
| Rate for Payer: First Health Commercial |
$563.35
|
| Rate for Payer: Humana Commercial |
$504.05
|
| Rate for Payer: Humana KY Medicaid |
$203.93
|
| Rate for Payer: Humana Medicare Advantage |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$206.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$486.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$437.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$208.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$521.84
|
| Rate for Payer: Ohio Health Group HMO |
$444.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$183.83
|
| Rate for Payer: PHCS Commercial |
$569.28
|
| Rate for Payer: United Healthcare All Payer |
$521.84
|
| Rate for Payer: Aetna Commercial |
$456.61
|
| Rate for Payer: Anthem Medicaid |
$203.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$462.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.35
|
|
|
ESOPHAGEAL CAPSULE ENDOSCOP(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 91111
|
| Hospital Charge Code |
750P0007
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$68.82 |
| Max. Negotiated Rate |
$1,020.39 |
| Rate for Payer: Aetna Commercial |
$1,020.39
|
| Rate for Payer: Anthem Medicaid |
$584.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$942.95
|
| Rate for Payer: Healthspan PPO |
$835.02
|
| Rate for Payer: Humana Medicaid |
$584.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$595.94
|
| Rate for Payer: Molina Healthcare Passport |
$584.25
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$590.09
|
|
|
ESOPHAGEAL CAPSULE ENDOSCOP(T
|
Facility
|
OP
|
$1,125.00
|
|
|
Service Code
|
HCPCS 91111
|
| Hospital Charge Code |
750T0007
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$866.25
|
| Rate for Payer: Anthem Medicaid |
$386.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.50
|
| 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 |
$562.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$933.75
|
| Rate for Payer: First Health Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial |
$956.25
|
| Rate for Payer: Humana KY Medicaid |
$386.89
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$390.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$394.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.00
|
| Rate for Payer: Ohio Health Group HMO |
$843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.75
|
| Rate for Payer: PHCS Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare All Payer |
$990.00
|
|
|
ESOPHAGEAL CAPSULE ENDOSCOP(T
|
Facility
|
IP
|
$1,125.00
|
|
|
Service Code
|
HCPCS 91111
|
| Hospital Charge Code |
750T0007
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$866.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$933.75
|
| Rate for Payer: First Health Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial |
$956.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.00
|
| Rate for Payer: Ohio Health Group HMO |
$843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.75
|
| Rate for Payer: PHCS Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare All Payer |
$990.00
|
|
|
ESOPHAGEAL CAPSULE ENDOSCOPY
|
Facility
|
OP
|
$1,375.00
|
|
|
Service Code
|
HCPCS 91111
|
| Hospital Charge Code |
75000007
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$178.75 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna Commercial |
$1,058.75
|
| Rate for Payer: Anthem Medicaid |
$472.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,072.50
|
| 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 |
$687.50
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Cigna Commercial |
$1,141.25
|
| Rate for Payer: First Health Commercial |
$1,306.25
|
| Rate for Payer: Humana Commercial |
$1,168.75
|
| Rate for Payer: Humana KY Medicaid |
$472.86
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$477.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,127.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,014.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$482.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,210.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$426.25
|
| Rate for Payer: PHCS Commercial |
$1,320.00
|
| Rate for Payer: United Healthcare All Payer |
$1,210.00
|
|
|
ESOPHAGEAL CAPSULE ENDOSCOPY
|
Facility
|
IP
|
$1,375.00
|
|
|
Service Code
|
HCPCS 91111
|
| Hospital Charge Code |
75000007
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$178.75 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna Commercial |
$1,058.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,072.50
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Cigna Commercial |
$1,141.25
|
| Rate for Payer: First Health Commercial |
$1,306.25
|
| Rate for Payer: Humana Commercial |
$1,168.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,127.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,014.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$412.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,210.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$426.25
|
| Rate for Payer: PHCS Commercial |
$1,320.00
|
| Rate for Payer: United Healthcare All Payer |
$1,210.00
|
|
|
ESOPHAGEAL CAPSULE ENDOSCOPY
|
Professional
|
Both
|
$1,375.00
|
|
|
Service Code
|
HCPCS 91111
|
| Hospital Charge Code |
75000007
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$68.82 |
| Max. Negotiated Rate |
$1,375.00 |
| Rate for Payer: Aetna Commercial |
$1,020.39
|
| Rate for Payer: Anthem Medicaid |
$584.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,375.00
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Cigna Commercial |
$942.95
|
| Rate for Payer: Healthspan PPO |
$835.02
|
| Rate for Payer: Humana Medicaid |
$584.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$595.94
|
| Rate for Payer: Molina Healthcare Passport |
$584.25
|
| Rate for Payer: Multiplan PHCS |
$825.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$962.50
|
| Rate for Payer: UHCCP Medicaid |
$481.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$590.09
|
|
|
ESOPHAGEAL FUNCTION IMPEDENCE
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
HCPCS 91037
|
| Hospital Charge Code |
75000004
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$133.25 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$789.25
|
| Rate for Payer: Anthem Medicaid |
$352.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$799.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$850.75
|
| Rate for Payer: First Health Commercial |
$973.75
|
| Rate for Payer: Humana Commercial |
$871.25
|
| Rate for Payer: Humana KY Medicaid |
$352.50
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$356.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$840.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$756.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$359.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$902.00
|
| Rate for Payer: Ohio Health Group HMO |
$768.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$205.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$317.75
|
| Rate for Payer: PHCS Commercial |
$984.00
|
| Rate for Payer: United Healthcare All Payer |
$902.00
|
|
|
ESOPHAGEAL FUNCTION IMPEDENCE
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
HCPCS 91037
|
| Hospital Charge Code |
75000004
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$133.25 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$789.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$799.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$850.75
|
| Rate for Payer: First Health Commercial |
$973.75
|
| Rate for Payer: Humana Commercial |
$871.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$840.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$756.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$902.00
|
| Rate for Payer: Ohio Health Group HMO |
$768.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$205.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$317.75
|
| Rate for Payer: PHCS Commercial |
$984.00
|
| Rate for Payer: United Healthcare All Payer |
$902.00
|
|
|
ESOPHAGEAL FUNCTION IMPEDENCE
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 91037
|
| Hospital Charge Code |
75000004
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$67.88 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna Commercial |
$237.42
|
| Rate for Payer: Anthem Medicaid |
$106.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,025.00
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$196.36
|
| Rate for Payer: Healthspan PPO |
$194.29
|
| Rate for Payer: Humana Medicaid |
$106.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.78
|
| Rate for Payer: Molina Healthcare Passport |
$106.65
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$717.50
|
| Rate for Payer: UHCCP Medicaid |
$358.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.72
|
|
|
ESOPHAGEAL FUNCTION IMPEDENC(P
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 91037
|
| Hospital Charge Code |
750P0004
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$67.88 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Aetna Commercial |
$237.42
|
| Rate for Payer: Anthem Medicaid |
$106.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$196.36
|
| Rate for Payer: Healthspan PPO |
$194.29
|
| Rate for Payer: Humana Medicaid |
$106.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.78
|
| Rate for Payer: Molina Healthcare Passport |
$106.65
|
| Rate for Payer: Multiplan PHCS |
$156.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.00
|
| Rate for Payer: UHCCP Medicaid |
$91.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.72
|
|
|
ESOPHAGEAL FUNCTION IMPEDENC(T
|
Facility
|
OP
|
$765.00
|
|
|
Service Code
|
HCPCS 91037
|
| Hospital Charge Code |
750T0004
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$734.40 |
| Rate for Payer: Aetna Commercial |
$589.05
|
| Rate for Payer: Anthem Medicaid |
$263.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$596.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$634.95
|
| Rate for Payer: First Health Commercial |
$726.75
|
| Rate for Payer: Humana Commercial |
$650.25
|
| Rate for Payer: Humana KY Medicaid |
$263.08
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$265.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$627.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$564.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$268.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$673.20
|
| Rate for Payer: Ohio Health Group HMO |
$573.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.15
|
| Rate for Payer: PHCS Commercial |
$734.40
|
| Rate for Payer: United Healthcare All Payer |
$673.20
|
|
|
ESOPHAGEAL FUNCTION IMPEDENC(T
|
Facility
|
IP
|
$765.00
|
|
|
Service Code
|
HCPCS 91037
|
| Hospital Charge Code |
750T0004
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$734.40 |
| Rate for Payer: Aetna Commercial |
$589.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$596.70
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$634.95
|
| Rate for Payer: First Health Commercial |
$726.75
|
| Rate for Payer: Humana Commercial |
$650.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$627.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$564.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$673.20
|
| Rate for Payer: Ohio Health Group HMO |
$573.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.15
|
| Rate for Payer: PHCS Commercial |
$734.40
|
| Rate for Payer: United Healthcare All Payer |
$673.20
|
|
|
ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC
|
Facility
|
IP
|
$14,923.41
|
|
|
Service Code
|
MSDRG 391
|
| Min. Negotiated Rate |
$10,126.60 |
| Max. Negotiated Rate |
$14,923.41 |
| Rate for Payer: Anthem Medicaid |
$10,126.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,659.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14,923.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,390.43
|
| Rate for Payer: Humana KY Medicaid |
$10,126.60
|
| Rate for Payer: Humana Medicare Advantage |
$10,659.58
|
| Rate for Payer: Kentucky WC Medicaid |
$10,227.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,791.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,329.13
|
|
|
ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$9,190.13
|
|
|
Service Code
|
MSDRG 392
|
| Min. Negotiated Rate |
$6,236.16 |
| Max. Negotiated Rate |
$9,190.13 |
| Rate for Payer: Anthem Medicaid |
$6,236.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,564.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,190.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,861.91
|
| Rate for Payer: Humana KY Medicaid |
$6,236.16
|
| Rate for Payer: Humana Medicare Advantage |
$6,564.38
|
| Rate for Payer: Kentucky WC Medicaid |
$6,298.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,877.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,360.88
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$1,097.45
|
|
|
Service Code
|
CPT 43235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$783.89 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
|
Facility
|
OP
|
$2,303.66
|
|
|
Service Code
|
CPT 43270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,645.47 |
| Max. Negotiated Rate |
$2,303.66 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES
|
Facility
|
OP
|
$2,303.66
|
|
|
Service Code
|
CPT 43244
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,645.47 |
| Max. Negotiated Rate |
$2,303.66 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE
|
Facility
|
OP
|
$1,097.45
|
|
|
Service Code
|
CPT 43239
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$783.89 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD
|
Facility
|
OP
|
$2,303.66
|
|
|
Service Code
|
CPT 43255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,645.47 |
| Max. Negotiated Rate |
$2,303.66 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
|
