|
ESOPHAGUS ULTRASOUND(T
|
Facility
|
OP
|
$3,474.93
|
|
|
Service Code
|
HCPCS 43231
|
| Hospital Charge Code |
761T1734
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$451.74 |
| Max. Negotiated Rate |
$3,335.93 |
| Rate for Payer: Aetna Commercial |
$2,675.70
|
| Rate for Payer: Anthem Medicaid |
$1,195.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,710.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Cash Price |
$1,737.46
|
| Rate for Payer: Cash Price |
$1,737.46
|
| Rate for Payer: Cigna Commercial |
$2,884.19
|
| Rate for Payer: First Health Commercial |
$3,301.18
|
| Rate for Payer: Humana Commercial |
$2,953.69
|
| Rate for Payer: Humana KY Medicaid |
$1,195.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,207.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,849.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,564.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,219.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,057.94
|
| Rate for Payer: Ohio Health Group HMO |
$2,606.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$694.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,077.23
|
| Rate for Payer: PHCS Commercial |
$3,335.93
|
| Rate for Payer: United Healthcare All Payer |
$3,057.94
|
|
|
ESOPH ENDOSCOPE - DILATION
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 43249
|
| Hospital Charge Code |
76101745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$2,303.66 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.54
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
ESOPH ENDOSCOPE - DILATION
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 43249
|
| Hospital Charge Code |
76101745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.61 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$266.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$145.61
|
| Rate for Payer: Anthem Medicaid |
$192.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$239.34
|
| Rate for Payer: Healthspan PPO |
$224.36
|
| Rate for Payer: Humana Medicaid |
$192.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$196.28
|
| Rate for Payer: Molina Healthcare Passport |
$192.43
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$152.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.35
|
|
|
ESOPH ENDOSCOPE - DILATION
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 43249
|
| Hospital Charge Code |
76101745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
ESOPH ENDOSCOPE - DILATION(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 43249
|
| Hospital Charge Code |
761P1745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.61 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$266.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$145.61
|
| Rate for Payer: Anthem Medicaid |
$192.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$239.34
|
| Rate for Payer: Healthspan PPO |
$224.36
|
| Rate for Payer: Humana Medicaid |
$192.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$196.28
|
| Rate for Payer: Molina Healthcare Passport |
$192.43
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$152.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.35
|
|
|
ESOPH FUNC PROLONG 1HR-24HR
|
Professional
|
Both
|
$1,033.00
|
|
|
Service Code
|
HCPCS 91038
|
| Hospital Charge Code |
75000005
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$75.36 |
| Max. Negotiated Rate |
$1,033.00 |
| Rate for Payer: Aetna Commercial |
$210.67
|
| Rate for Payer: Anthem Medicaid |
$92.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,033.00
|
| Rate for Payer: Cash Price |
$516.50
|
| Rate for Payer: Cash Price |
$516.50
|
| Rate for Payer: Cigna Commercial |
$169.91
|
| Rate for Payer: Healthspan PPO |
$172.40
|
| Rate for Payer: Humana Medicaid |
$92.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.24
|
| Rate for Payer: Molina Healthcare Passport |
$92.39
|
| Rate for Payer: Multiplan PHCS |
$619.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$723.10
|
| Rate for Payer: UHCCP Medicaid |
$361.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.31
|
|
|
ESOPH FUNC PROLONG 1HR-24HR
|
Facility
|
IP
|
$1,033.00
|
|
|
Service Code
|
HCPCS 91038
|
| Hospital Charge Code |
75000005
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$134.29 |
| Max. Negotiated Rate |
$991.68 |
| Rate for Payer: Aetna Commercial |
$795.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$805.74
|
| Rate for Payer: Cash Price |
$516.50
|
| Rate for Payer: Cigna Commercial |
$857.39
|
| Rate for Payer: First Health Commercial |
$981.35
|
| Rate for Payer: Humana Commercial |
$878.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$847.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$762.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$909.04
|
| Rate for Payer: Ohio Health Group HMO |
$774.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$320.23
|
| Rate for Payer: PHCS Commercial |
$991.68
|
| Rate for Payer: United Healthcare All Payer |
$909.04
|
|
|
ESOPH FUNC PROLONG 1HR-24HR
|
Facility
|
OP
|
$1,033.00
|
|
|
Service Code
|
HCPCS 91038
|
| Hospital Charge Code |
75000005
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$134.29 |
| Max. Negotiated Rate |
$991.68 |
| Rate for Payer: Aetna Commercial |
$795.41
|
| Rate for Payer: Anthem Medicaid |
$355.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$805.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$516.50
|
| Rate for Payer: Cash Price |
$516.50
|
| Rate for Payer: Cigna Commercial |
$857.39
|
| Rate for Payer: First Health Commercial |
$981.35
|
| Rate for Payer: Humana Commercial |
$878.05
|
| Rate for Payer: Humana KY Medicaid |
$355.25
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$358.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$847.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$762.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$362.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$909.04
|
| Rate for Payer: Ohio Health Group HMO |
$774.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$320.23
|
| Rate for Payer: PHCS Commercial |
$991.68
|
| Rate for Payer: United Healthcare All Payer |
$909.04
|
|
|
ESOPH FUNC PROLONG 1HR-24HR(P
|
Professional
|
Both
|
$270.00
|
|
|
Service Code
|
HCPCS 91038
|
| Hospital Charge Code |
750P0005
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$75.36 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$210.67
|
| Rate for Payer: Anthem Medicaid |
$92.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$270.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$169.91
|
| Rate for Payer: Healthspan PPO |
$172.40
|
| Rate for Payer: Humana Medicaid |
$92.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.24
|
| Rate for Payer: Molina Healthcare Passport |
$92.39
|
| Rate for Payer: Multiplan PHCS |
$162.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$189.00
|
| Rate for Payer: UHCCP Medicaid |
$94.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.31
|
|
|
ESOPH FUNC PROLONG 1HR-24HR(T
|
Facility
|
OP
|
$763.00
|
|
|
Service Code
|
HCPCS 91038
|
| Hospital Charge Code |
750T0005
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem Medicaid |
$262.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Humana KY Medicaid |
$262.40
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$265.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
ESOPH FUNC PROLONG 1HR-24HR(T
|
Facility
|
IP
|
$763.00
|
|
|
Service Code
|
HCPCS 91038
|
| Hospital Charge Code |
750T0005
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
ESOPH FUNDOPLASTY LAP
|
Facility
|
OP
|
$1,925.00
|
|
|
Service Code
|
HCPCS 43327
|
| Hospital Charge Code |
76101769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$250.25 |
| Max. Negotiated Rate |
$1,848.00 |
| Rate for Payer: Aetna Commercial |
$1,482.25
|
| Rate for Payer: Anthem Medicaid |
$662.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,501.50
|
| Rate for Payer: Cash Price |
$962.50
|
| Rate for Payer: Cigna Commercial |
$1,597.75
|
| Rate for Payer: First Health Commercial |
$1,828.75
|
| Rate for Payer: Humana Commercial |
$1,636.25
|
| Rate for Payer: Humana KY Medicaid |
$662.01
|
| Rate for Payer: Kentucky WC Medicaid |
$668.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,578.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,420.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$577.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$675.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,694.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,443.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$596.75
|
| Rate for Payer: PHCS Commercial |
$1,848.00
|
| Rate for Payer: United Healthcare All Payer |
$1,694.00
|
|
|
ESOPH FUNDOPLASTY LAP
|
Facility
|
IP
|
$1,925.00
|
|
|
Service Code
|
HCPCS 43327
|
| Hospital Charge Code |
76101769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$250.25 |
| Max. Negotiated Rate |
$1,848.00 |
| Rate for Payer: Aetna Commercial |
$1,482.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,501.50
|
| Rate for Payer: Cash Price |
$962.50
|
| Rate for Payer: Cigna Commercial |
$1,597.75
|
| Rate for Payer: First Health Commercial |
$1,828.75
|
| Rate for Payer: Humana Commercial |
$1,636.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,578.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,420.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$577.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,694.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,443.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$596.75
|
| Rate for Payer: PHCS Commercial |
$1,848.00
|
| Rate for Payer: United Healthcare All Payer |
$1,694.00
|
|
|
ESOPH FUNDOPLASTY LAP
|
Professional
|
Both
|
$1,925.00
|
|
|
Service Code
|
HCPCS 43327
|
| Hospital Charge Code |
76101769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$673.75 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna Commercial |
$1,340.53
|
| Rate for Payer: Anthem Medicaid |
$721.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,925.00
|
| Rate for Payer: Cash Price |
$962.50
|
| Rate for Payer: Cash Price |
$962.50
|
| Rate for Payer: Cigna Commercial |
$1,396.89
|
| Rate for Payer: Healthspan PPO |
$848.66
|
| Rate for Payer: Humana Medicaid |
$721.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,068.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$735.71
|
| Rate for Payer: Molina Healthcare Passport |
$721.28
|
| Rate for Payer: Multiplan PHCS |
$1,155.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,347.50
|
| Rate for Payer: UHCCP Medicaid |
$673.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$728.49
|
|
|
ESOPH FUNDOPLASTY LAP(P
|
Professional
|
Both
|
$1,925.00
|
|
|
Service Code
|
HCPCS 43327
|
| Hospital Charge Code |
761P1769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$673.75 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna Commercial |
$1,340.53
|
| Rate for Payer: Anthem Medicaid |
$721.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,925.00
|
| Rate for Payer: Cash Price |
$962.50
|
| Rate for Payer: Cash Price |
$962.50
|
| Rate for Payer: Cigna Commercial |
$1,396.89
|
| Rate for Payer: Healthspan PPO |
$848.66
|
| Rate for Payer: Humana Medicaid |
$721.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,068.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$735.71
|
| Rate for Payer: Molina Healthcare Passport |
$721.28
|
| Rate for Payer: Multiplan PHCS |
$1,155.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,347.50
|
| Rate for Payer: UHCCP Medicaid |
$673.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$728.49
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
OP
|
$2,845.00
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101770
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.85 |
| Max. Negotiated Rate |
$2,731.20 |
| Rate for Payer: Aetna Commercial |
$2,190.65
|
| Rate for Payer: Anthem Medicaid |
$978.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,219.10
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$2,361.35
|
| Rate for Payer: First Health Commercial |
$2,702.75
|
| Rate for Payer: Humana Commercial |
$2,418.25
|
| Rate for Payer: Humana KY Medicaid |
$978.40
|
| Rate for Payer: Kentucky WC Medicaid |
$988.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,332.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,099.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$853.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$998.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,503.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,133.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$881.95
|
| Rate for Payer: PHCS Commercial |
$2,731.20
|
| Rate for Payer: United Healthcare All Payer |
$2,503.60
|
|
|
ESOPH FUNDOPLASTY THOR
|
Professional
|
Both
|
$2,845.00
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101770
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$995.75 |
| Max. Negotiated Rate |
$2,845.00 |
| Rate for Payer: Aetna Commercial |
$1,981.62
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,845.00
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$2,054.37
|
| Rate for Payer: Healthspan PPO |
$1,253.77
|
| Rate for Payer: Humana Medicaid |
$1,059.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,579.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,080.71
|
| Rate for Payer: Molina Healthcare Passport |
$1,059.52
|
| Rate for Payer: Multiplan PHCS |
$1,707.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,991.50
|
| Rate for Payer: UHCCP Medicaid |
$995.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
|
|
ESOPH FUNDOPLASTY THOR
|
Professional
|
Both
|
$1,422.50
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$497.88 |
| Max. Negotiated Rate |
$2,054.37 |
| Rate for Payer: Aetna Commercial |
$1,981.62
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,422.50
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cigna Commercial |
$2,054.37
|
| Rate for Payer: Healthspan PPO |
$1,253.77
|
| Rate for Payer: Humana Medicaid |
$1,059.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,579.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,080.71
|
| Rate for Payer: Molina Healthcare Passport |
$1,059.52
|
| Rate for Payer: Multiplan PHCS |
$853.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$995.75
|
| Rate for Payer: UHCCP Medicaid |
$497.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
IP
|
$1,422.50
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$184.92 |
| Max. Negotiated Rate |
$1,365.60 |
| Rate for Payer: Aetna Commercial |
$1,095.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,109.55
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cigna Commercial |
$1,180.68
|
| Rate for Payer: First Health Commercial |
$1,351.38
|
| Rate for Payer: Humana Commercial |
$1,209.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,166.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,049.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$426.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,251.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,066.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$184.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$440.98
|
| Rate for Payer: PHCS Commercial |
$1,365.60
|
| Rate for Payer: United Healthcare All Payer |
$1,251.80
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
OP
|
$1,422.50
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$184.92 |
| Max. Negotiated Rate |
$1,365.60 |
| Rate for Payer: Aetna Commercial |
$1,095.32
|
| Rate for Payer: Anthem Medicaid |
$489.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,109.55
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cigna Commercial |
$1,180.68
|
| Rate for Payer: First Health Commercial |
$1,351.38
|
| Rate for Payer: Humana Commercial |
$1,209.12
|
| Rate for Payer: Humana KY Medicaid |
$489.20
|
| Rate for Payer: Kentucky WC Medicaid |
$494.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,166.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,049.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$426.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$499.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,251.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,066.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$184.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$440.98
|
| Rate for Payer: PHCS Commercial |
$1,365.60
|
| Rate for Payer: United Healthcare All Payer |
$1,251.80
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
IP
|
$2,845.00
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101770
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.85 |
| Max. Negotiated Rate |
$2,731.20 |
| Rate for Payer: Aetna Commercial |
$2,190.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,219.10
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$2,361.35
|
| Rate for Payer: First Health Commercial |
$2,702.75
|
| Rate for Payer: Humana Commercial |
$2,418.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,332.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,099.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$853.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,503.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,133.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$881.95
|
| Rate for Payer: PHCS Commercial |
$2,731.20
|
| Rate for Payer: United Healthcare All Payer |
$2,503.60
|
|
|
ESOPH FUNDOPLASTY THOR(P
|
Professional
|
Both
|
$2,845.00
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
761P1770
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$995.75 |
| Max. Negotiated Rate |
$2,845.00 |
| Rate for Payer: Aetna Commercial |
$1,981.62
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,845.00
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$2,054.37
|
| Rate for Payer: Healthspan PPO |
$1,253.77
|
| Rate for Payer: Humana Medicaid |
$1,059.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,579.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,080.71
|
| Rate for Payer: Molina Healthcare Passport |
$1,059.52
|
| Rate for Payer: Multiplan PHCS |
$1,707.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,991.50
|
| Rate for Payer: UHCCP Medicaid |
$995.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
|
|
ESOPH FUNDOPLASTY THOR(P
|
Professional
|
Both
|
$1,422.50
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
761P1771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$497.88 |
| Max. Negotiated Rate |
$2,054.37 |
| Rate for Payer: Aetna Commercial |
$1,981.62
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,422.50
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cigna Commercial |
$2,054.37
|
| Rate for Payer: Healthspan PPO |
$1,253.77
|
| Rate for Payer: Humana Medicaid |
$1,059.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,579.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,080.71
|
| Rate for Payer: Molina Healthcare Passport |
$1,059.52
|
| Rate for Payer: Multiplan PHCS |
$853.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$995.75
|
| Rate for Payer: UHCCP Medicaid |
$497.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
76101727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.90 |
| Max. Negotiated Rate |
$349.97 |
| Rate for Payer: Aetna Commercial |
$195.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.86
|
| Rate for Payer: Anthem Medicaid |
$95.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$305.00
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$181.26
|
| Rate for Payer: Healthspan PPO |
$349.97
|
| Rate for Payer: Humana Medicaid |
$95.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.82
|
| Rate for Payer: Molina Healthcare Passport |
$95.90
|
| Rate for Payer: Multiplan PHCS |
$183.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$213.50
|
| Rate for Payer: UHCCP Medicaid |
$110.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.86
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
76101727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.65 |
| Max. Negotiated Rate |
$2,303.66 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem Medicaid |
$104.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Humana KY Medicaid |
$104.89
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Kentucky WC Medicaid |
$105.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.55
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
