|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
76101727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.65 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| 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: 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 |
$91.50
|
| 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
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ(P
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
761P1727
|
|
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
|
|
|
ESPHG THRSC MOBLJ
|
Professional
|
Both
|
$4,025.00
|
|
|
Service Code
|
HCPCS 43288
|
| Hospital Charge Code |
76101767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,408.75 |
| Max. Negotiated Rate |
$6,244.90 |
| Rate for Payer: Anthem Medicaid |
$2,995.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,025.00
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cigna Commercial |
$6,244.90
|
| Rate for Payer: Humana Medicaid |
$2,995.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5,093.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,055.27
|
| Rate for Payer: Molina Healthcare Passport |
$2,995.36
|
| Rate for Payer: Multiplan PHCS |
$2,415.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,817.50
|
| Rate for Payer: UHCCP Medicaid |
$1,408.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,025.31
|
|
|
ESPHG THRSC MOBLJ
|
Facility
|
IP
|
$4,025.00
|
|
|
Service Code
|
HCPCS 43288
|
| Hospital Charge Code |
76101767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$523.25 |
| Max. Negotiated Rate |
$3,864.00 |
| Rate for Payer: Aetna Commercial |
$3,099.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,139.50
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cigna Commercial |
$3,340.75
|
| Rate for Payer: First Health Commercial |
$3,823.75
|
| Rate for Payer: Humana Commercial |
$3,421.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,300.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,970.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,207.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,542.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,018.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.75
|
| Rate for Payer: PHCS Commercial |
$3,864.00
|
| Rate for Payer: United Healthcare All Payer |
$3,542.00
|
|
|
ESPHG THRSC MOBLJ
|
Facility
|
OP
|
$4,025.00
|
|
|
Service Code
|
HCPCS 43288
|
| Hospital Charge Code |
76101767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$523.25 |
| Max. Negotiated Rate |
$3,864.00 |
| Rate for Payer: Aetna Commercial |
$3,099.25
|
| Rate for Payer: Anthem Medicaid |
$1,384.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,139.50
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cigna Commercial |
$3,340.75
|
| Rate for Payer: First Health Commercial |
$3,823.75
|
| Rate for Payer: Humana Commercial |
$3,421.25
|
| Rate for Payer: Humana KY Medicaid |
$1,384.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,398.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,300.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,970.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,207.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,411.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,542.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,018.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.75
|
| Rate for Payer: PHCS Commercial |
$3,864.00
|
| Rate for Payer: United Healthcare All Payer |
$3,542.00
|
|
|
ESPHG THRSC MOBLJ(P
|
Professional
|
Both
|
$4,025.00
|
|
|
Service Code
|
HCPCS 43288
|
| Hospital Charge Code |
761P1767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,408.75 |
| Max. Negotiated Rate |
$6,244.90 |
| Rate for Payer: Anthem Medicaid |
$2,995.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,025.00
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cigna Commercial |
$6,244.90
|
| Rate for Payer: Humana Medicaid |
$2,995.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5,093.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,055.27
|
| Rate for Payer: Molina Healthcare Passport |
$2,995.36
|
| Rate for Payer: Multiplan PHCS |
$2,415.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,817.50
|
| Rate for Payer: UHCCP Medicaid |
$1,408.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,025.31
|
|
|
ESPHG TOT W/LAPS MOBLJ
|
Facility
|
IP
|
$3,475.00
|
|
|
Service Code
|
HCPCS 43286
|
| Hospital Charge Code |
36001272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$451.75 |
| Max. Negotiated Rate |
$3,336.00 |
| Rate for Payer: Aetna Commercial |
$2,675.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,710.50
|
| Rate for Payer: Cash Price |
$1,737.50
|
| Rate for Payer: Cigna Commercial |
$2,884.25
|
| Rate for Payer: First Health Commercial |
$3,301.25
|
| Rate for Payer: Humana Commercial |
$2,953.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,849.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,564.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,042.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,058.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,606.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$695.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,077.25
|
| Rate for Payer: PHCS Commercial |
$3,336.00
|
| Rate for Payer: United Healthcare All Payer |
$3,058.00
|
|
|
ESPHG TOT W/LAPS MOBLJ
|
Professional
|
Both
|
$3,475.00
|
|
|
Service Code
|
HCPCS 43286
|
| Hospital Charge Code |
36001272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,216.25 |
| Max. Negotiated Rate |
$5,237.85 |
| Rate for Payer: Anthem Medicaid |
$2,511.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,475.00
|
| Rate for Payer: Cash Price |
$1,737.50
|
| Rate for Payer: Cash Price |
$1,737.50
|
| Rate for Payer: Cigna Commercial |
$5,237.85
|
| Rate for Payer: Humana Medicaid |
$2,511.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4,271.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$2,561.73
|
| Rate for Payer: Molina Healthcare Passport |
$2,511.50
|
| Rate for Payer: Multiplan PHCS |
$2,085.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,432.50
|
| Rate for Payer: UHCCP Medicaid |
$1,216.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,536.62
|
|
|
ESPHG TOT W/LAPS MOBLJ
|
Facility
|
OP
|
$3,475.00
|
|
|
Service Code
|
HCPCS 43286
|
| Hospital Charge Code |
36001272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$451.75 |
| Max. Negotiated Rate |
$3,336.00 |
| Rate for Payer: Aetna Commercial |
$2,675.75
|
| Rate for Payer: Anthem Medicaid |
$1,195.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,710.50
|
| Rate for Payer: Cash Price |
$1,737.50
|
| Rate for Payer: Cigna Commercial |
$2,884.25
|
| Rate for Payer: First Health Commercial |
$3,301.25
|
| Rate for Payer: Humana Commercial |
$2,953.75
|
| Rate for Payer: Humana KY Medicaid |
$1,195.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,207.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,849.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,564.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,042.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,219.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,058.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,606.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$695.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,077.25
|
| Rate for Payer: PHCS Commercial |
$3,336.00
|
| Rate for Payer: United Healthcare All Payer |
$3,058.00
|
|
|
ESPHG TOT W/LAPS MOBLJ
|
Professional
|
Both
|
$3,475.00
|
|
|
Service Code
|
HCPCS 43286
|
| Hospital Charge Code |
360P1272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,216.25 |
| Max. Negotiated Rate |
$5,237.85 |
| Rate for Payer: Anthem Medicaid |
$2,511.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,475.00
|
| Rate for Payer: Cash Price |
$1,737.50
|
| Rate for Payer: Cash Price |
$1,737.50
|
| Rate for Payer: Cigna Commercial |
$5,237.85
|
| Rate for Payer: Humana Medicaid |
$2,511.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4,271.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$2,561.73
|
| Rate for Payer: Molina Healthcare Passport |
$2,511.50
|
| Rate for Payer: Multiplan PHCS |
$2,085.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,432.50
|
| Rate for Payer: UHCCP Medicaid |
$1,216.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,536.62
|
|
|
ESPHG TOT W/THRCM
|
Facility
|
OP
|
$2,955.00
|
|
|
Service Code
|
HCPCS 43112
|
| Hospital Charge Code |
76101719
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.15 |
| Max. Negotiated Rate |
$2,836.80 |
| Rate for Payer: Aetna Commercial |
$2,275.35
|
| Rate for Payer: Anthem Medicaid |
$1,016.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,304.90
|
| Rate for Payer: Cash Price |
$1,477.50
|
| Rate for Payer: Cigna Commercial |
$2,452.65
|
| Rate for Payer: First Health Commercial |
$2,807.25
|
| Rate for Payer: Humana Commercial |
$2,511.75
|
| Rate for Payer: Humana KY Medicaid |
$1,016.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,026.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,423.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,180.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$886.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,036.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,600.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,216.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$591.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$916.05
|
| Rate for Payer: PHCS Commercial |
$2,836.80
|
| Rate for Payer: United Healthcare All Payer |
$2,600.40
|
|
|
ESPHG TOT W/THRCM
|
Facility
|
IP
|
$2,955.00
|
|
|
Service Code
|
HCPCS 43112
|
| Hospital Charge Code |
76101719
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.15 |
| Max. Negotiated Rate |
$2,836.80 |
| Rate for Payer: Aetna Commercial |
$2,275.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,304.90
|
| Rate for Payer: Cash Price |
$1,477.50
|
| Rate for Payer: Cigna Commercial |
$2,452.65
|
| Rate for Payer: First Health Commercial |
$2,807.25
|
| Rate for Payer: Humana Commercial |
$2,511.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,423.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,180.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$886.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,600.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,216.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$591.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$916.05
|
| Rate for Payer: PHCS Commercial |
$2,836.80
|
| Rate for Payer: United Healthcare All Payer |
$2,600.40
|
|
|
ESPHG TOT W/THRCM
|
Professional
|
Both
|
$2,955.00
|
|
|
Service Code
|
HCPCS 43112
|
| Hospital Charge Code |
76101719
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,034.25 |
| Max. Negotiated Rate |
$4,123.50 |
| Rate for Payer: Aetna Commercial |
$4,123.50
|
| Rate for Payer: Anthem Medicaid |
$1,553.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,955.00
|
| Rate for Payer: Cash Price |
$1,477.50
|
| Rate for Payer: Cash Price |
$1,477.50
|
| Rate for Payer: Cigna Commercial |
$3,875.20
|
| Rate for Payer: Healthspan PPO |
$3,477.42
|
| Rate for Payer: Humana Medicaid |
$1,553.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,571.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,584.94
|
| Rate for Payer: Molina Healthcare Passport |
$1,553.86
|
| Rate for Payer: Multiplan PHCS |
$1,773.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,068.50
|
| Rate for Payer: UHCCP Medicaid |
$1,034.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,569.40
|
|
|
ESPHG TOT W/THRCM(P
|
Professional
|
Both
|
$2,955.00
|
|
|
Service Code
|
HCPCS 43112
|
| Hospital Charge Code |
761P1719
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,034.25 |
| Max. Negotiated Rate |
$4,123.50 |
| Rate for Payer: Aetna Commercial |
$4,123.50
|
| Rate for Payer: Anthem Medicaid |
$1,553.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,955.00
|
| Rate for Payer: Cash Price |
$1,477.50
|
| Rate for Payer: Cash Price |
$1,477.50
|
| Rate for Payer: Cigna Commercial |
$3,875.20
|
| Rate for Payer: Healthspan PPO |
$3,477.42
|
| Rate for Payer: Humana Medicaid |
$1,553.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,571.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,584.94
|
| Rate for Payer: Molina Healthcare Passport |
$1,553.86
|
| Rate for Payer: Multiplan PHCS |
$1,773.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,068.50
|
| Rate for Payer: UHCCP Medicaid |
$1,034.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,569.40
|
|
|
ESSURE (TUBAL)
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 58565
|
| Hospital Charge Code |
76102239
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$3,840.00 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
ESSURE (TUBAL)
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 58565
|
| Hospital Charge Code |
76102239
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$6,021.69 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem Medicaid |
$1,375.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,301.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,021.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,806.63
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Humana KY Medicaid |
$1,375.60
|
| Rate for Payer: Humana Medicare Advantage |
$4,301.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,389.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,161.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,403.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
ESSURE (TUBAL)
|
Professional
|
Both
|
$4,000.00
|
|
|
Service Code
|
HCPCS 58565
|
| Hospital Charge Code |
76102239
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.83 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$684.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$330.83
|
| Rate for Payer: Anthem Medicaid |
$338.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$2,390.39
|
| Rate for Payer: Healthspan PPO |
$2,725.21
|
| Rate for Payer: Humana Medicaid |
$338.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$563.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$345.39
|
| Rate for Payer: Molina Healthcare Passport |
$338.62
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,800.00
|
| Rate for Payer: UHCCP Medicaid |
$347.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$342.01
|
|
|
ESSURE (TUBAL)(P
|
Professional
|
Both
|
$4,000.00
|
|
|
Service Code
|
HCPCS 58565
|
| Hospital Charge Code |
761P2239
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.83 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$684.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$330.83
|
| Rate for Payer: Anthem Medicaid |
$338.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$2,390.39
|
| Rate for Payer: Healthspan PPO |
$2,725.21
|
| Rate for Payer: Humana Medicaid |
$338.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$563.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$345.39
|
| Rate for Payer: Molina Healthcare Passport |
$338.62
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,800.00
|
| Rate for Payer: UHCCP Medicaid |
$347.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$342.01
|
|
|
ESTABLISH ACCESS TO ARTERY
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 36100
|
| Hospital Charge Code |
76101436
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.03 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$276.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$111.03
|
| Rate for Payer: Anthem Medicaid |
$165.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$258.91
|
| Rate for Payer: Healthspan PPO |
$832.86
|
| Rate for Payer: Humana Medicaid |
$165.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$215.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.18
|
| Rate for Payer: Molina Healthcare Passport |
$165.86
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$116.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.52
|
|
|
ESTABLISH ACCESS TO ARTERY
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 36100
|
| Hospital Charge Code |
76101436
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
ESTABLISH ACCESS TO ARTERY
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 36100
|
| Hospital Charge Code |
76101436
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem Medicaid |
$309.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Humana KY Medicaid |
$309.51
|
| Rate for Payer: Kentucky WC Medicaid |
$312.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
ESTABLISH ACCESS TO ARTERY(P
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 36100
|
| Hospital Charge Code |
761P1436
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.03 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$276.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$111.03
|
| Rate for Payer: Anthem Medicaid |
$165.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$258.91
|
| Rate for Payer: Healthspan PPO |
$832.86
|
| Rate for Payer: Humana Medicaid |
$165.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$215.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.18
|
| Rate for Payer: Molina Healthcare Passport |
$165.86
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$116.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.52
|
|
|
EST PT HIGH LEVEL 4
|
Facility
|
IP
|
$474.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000009
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$455.04 |
| Rate for Payer: Aetna Commercial |
$364.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$369.72
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$393.42
|
| Rate for Payer: First Health Commercial |
$450.30
|
| Rate for Payer: Humana Commercial |
$402.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$388.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$349.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$417.12
|
| Rate for Payer: Ohio Health Group HMO |
$355.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.94
|
| Rate for Payer: PHCS Commercial |
$455.04
|
| Rate for Payer: United Healthcare All Payer |
$417.12
|
|
|
EST PT HIGH LEVEL 4
|
Professional
|
Both
|
$474.00
|
|
|
Service Code
|
HCPCS 99214
|
| Hospital Charge Code |
51000009
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$474.00 |
| Rate for Payer: Aetna Commercial |
$109.62
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.49
|
| Rate for Payer: Anthem Medicaid |
$61.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$474.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$136.31
|
| Rate for Payer: Healthspan PPO |
$106.96
|
| Rate for Payer: Humana Medicaid |
$61.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.22
|
| Rate for Payer: Molina Healthcare Passport |
$61.98
|
| Rate for Payer: Multiplan PHCS |
$284.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$331.80
|
| Rate for Payer: UHCCP Medicaid |
$51.96
|
| Rate for Payer: United Healthcare Non-Options |
$75.50
|
| Rate for Payer: United Healthcare Options |
$61.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$62.60
|
|
|
EST PT HIGH LEVEL 4
|
Facility
|
OP
|
$474.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000009
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$455.04 |
| Rate for Payer: Aetna Commercial |
$364.98
|
| Rate for Payer: Anthem Medicaid |
$163.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$369.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$393.42
|
| Rate for Payer: First Health Commercial |
$450.30
|
| Rate for Payer: Humana Commercial |
$402.90
|
| Rate for Payer: Humana KY Medicaid |
$163.01
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$164.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$388.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$349.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$166.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$417.12
|
| Rate for Payer: Ohio Health Group HMO |
$355.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.94
|
| Rate for Payer: PHCS Commercial |
$455.04
|
| Rate for Payer: United Healthcare All Payer |
$417.12
|
|
