|
ESOPH FUNDOPLASTY LAP
|
Facility
|
OP
|
$1,925.00
|
|
|
Service Code
|
HCPCS 43327
|
| Hospital Charge Code |
76101769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$577.50 |
| 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 |
$668.75
|
| 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 |
$1,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,674.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,328.25
|
| Rate for Payer: PHCS Commercial |
$1,848.00
|
| Rate for Payer: United Healthcare All Payer |
$1,694.00
|
|
|
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 |
$1,396.89 |
| Rate for Payer: Aetna Commercial |
$1,340.53
|
| Rate for Payer: Ambetter Exchange |
$795.06
|
| Rate for Payer: Anthem Medicaid |
$721.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$795.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$795.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$954.07
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$795.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$795.06
|
| 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 |
$1,033.58
|
| Rate for Payer: UHCCP Medicaid |
$673.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$728.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$795.06
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
OP
|
$2,845.00
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101770
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$853.50 |
| 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 |
$2,276.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,475.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,963.05
|
| Rate for Payer: PHCS Commercial |
$2,731.20
|
| Rate for Payer: United Healthcare All Payer |
$2,503.60
|
|
|
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: Ambetter Exchange |
$1,058.69
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,058.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,058.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,270.43
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,058.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,058.69
|
| 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 |
$1,376.30
|
| Rate for Payer: UHCCP Medicaid |
$497.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,058.69
|
|
|
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 |
$2,054.37 |
| Rate for Payer: Aetna Commercial |
$1,981.62
|
| Rate for Payer: Ambetter Exchange |
$1,058.69
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,058.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,058.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,270.43
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,058.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,058.69
|
| 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 |
$1,376.30
|
| Rate for Payer: UHCCP Medicaid |
$995.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,058.69
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
OP
|
$1,422.50
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.75 |
| Max. Negotiated Rate |
$1,365.60 |
| Rate for Payer: Aetna Commercial |
$1,095.33
|
| 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 |
$1,180.67
|
| 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 |
$1,049.81
|
| 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 |
$1,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$981.52
|
| 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 |
$853.50 |
| 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 |
$2,276.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,475.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,963.05
|
| Rate for Payer: PHCS Commercial |
$2,731.20
|
| Rate for Payer: United Healthcare All Payer |
$2,503.60
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
IP
|
$1,422.50
|
|
|
Service Code
|
HCPCS 43328
|
| Hospital Charge Code |
76101771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.75 |
| Max. Negotiated Rate |
$1,365.60 |
| Rate for Payer: Aetna Commercial |
$1,095.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,109.55
|
| Rate for Payer: Cash Price |
$711.25
|
| Rate for Payer: Cigna Commercial |
$1,180.67
|
| 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 |
$1,049.81
|
| 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 |
$1,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$981.52
|
| Rate for Payer: PHCS Commercial |
$1,365.60
|
| Rate for Payer: United Healthcare All Payer |
$1,251.80
|
|
|
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: Ambetter Exchange |
$1,058.69
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,058.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,058.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,270.43
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,058.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,058.69
|
| 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 |
$1,376.30
|
| Rate for Payer: UHCCP Medicaid |
$497.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,058.69
|
|
|
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 |
$2,054.37 |
| Rate for Payer: Aetna Commercial |
$1,981.62
|
| Rate for Payer: Ambetter Exchange |
$1,058.69
|
| Rate for Payer: Anthem Medicaid |
$1,059.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,058.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,058.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,270.43
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,058.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,058.69
|
| 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 |
$1,376.30
|
| Rate for Payer: UHCCP Medicaid |
$995.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,070.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,058.69
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
76101727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.89 |
| Max. Negotiated Rate |
$2,453.89 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem Medicaid |
$104.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,752.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,453.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,366.25
|
| Rate for Payer: Cash Price |
$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 |
$1,752.78
|
| 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 |
$2,103.34
|
| 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 |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
76101727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.50 |
| 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 |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
HCPCS 43201
|
| Hospital Charge Code |
76101727
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.91 |
| Max. Negotiated Rate |
$349.97 |
| Rate for Payer: Aetna Commercial |
$195.56
|
| Rate for Payer: Ambetter Exchange |
$96.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.86
|
| Rate for Payer: Anthem Medicaid |
$177.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$96.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$96.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$116.29
|
| 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 |
$177.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$96.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$180.90
|
| Rate for Payer: Molina Healthcare Passport |
$177.35
|
| Rate for Payer: Multiplan PHCS |
$183.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$125.98
|
| Rate for Payer: UHCCP Medicaid |
$110.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$179.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$96.91
|
|
|
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 |
$96.91 |
| Max. Negotiated Rate |
$349.97 |
| Rate for Payer: Aetna Commercial |
$195.56
|
| Rate for Payer: Ambetter Exchange |
$96.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.86
|
| Rate for Payer: Anthem Medicaid |
$177.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$96.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$96.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$116.29
|
| 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 |
$177.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$96.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$180.90
|
| Rate for Payer: Molina Healthcare Passport |
$177.35
|
| Rate for Payer: Multiplan PHCS |
$183.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$125.98
|
| Rate for Payer: UHCCP Medicaid |
$110.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$179.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$96.91
|
|
|
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: Ambetter Exchange |
$3,530.73
|
| Rate for Payer: Anthem Medicaid |
$2,995.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3,530.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,530.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,236.88
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3,530.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,530.73
|
| 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 |
$4,589.95
|
| Rate for Payer: UHCCP Medicaid |
$1,408.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,025.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$3,530.73
|
|
|
ESPHG THRSC MOBLJ
|
Facility
|
OP
|
$4,025.00
|
|
|
Service Code
|
HCPCS 43288
|
| Hospital Charge Code |
76101767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,207.50 |
| 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 |
$1,398.29
|
| 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 |
$3,220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,501.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,777.25
|
| Rate for Payer: PHCS Commercial |
$3,864.00
|
| Rate for Payer: United Healthcare All Payer |
$3,542.00
|
|
|
ESPHG THRSC MOBLJ
|
Facility
|
IP
|
$4,025.00
|
|
|
Service Code
|
HCPCS 43288
|
| Hospital Charge Code |
76101767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,207.50 |
| 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 |
$3,220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,501.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,777.25
|
| 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: Ambetter Exchange |
$3,530.73
|
| Rate for Payer: Anthem Medicaid |
$2,995.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3,530.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,530.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,236.88
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3,530.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,530.73
|
| 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 |
$4,589.95
|
| Rate for Payer: UHCCP Medicaid |
$1,408.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,025.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$3,530.73
|
|
|
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 |
$1,042.50 |
| 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 |
$2,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,023.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,397.75
|
| Rate for Payer: PHCS Commercial |
$3,336.00
|
| Rate for Payer: United Healthcare All Payer |
$3,058.00
|
|
|
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 |
$1,042.50 |
| 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 |
$1,207.21
|
| 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 |
$2,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,023.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,397.75
|
| 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: Ambetter Exchange |
$3,004.68
|
| Rate for Payer: Anthem Medicaid |
$2,511.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3,004.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,004.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,605.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3,004.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,004.68
|
| 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 |
$3,906.08
|
| Rate for Payer: UHCCP Medicaid |
$1,216.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,536.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$3,004.68
|
|
|
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: Ambetter Exchange |
$3,004.68
|
| Rate for Payer: Anthem Medicaid |
$2,511.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3,004.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,004.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,605.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3,004.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,004.68
|
| 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 |
$3,906.08
|
| Rate for Payer: UHCCP Medicaid |
$1,216.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,536.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$3,004.68
|
|
|
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 |
$4,185.09 |
| Rate for Payer: Aetna Commercial |
$4,123.50
|
| Rate for Payer: Ambetter Exchange |
$3,219.30
|
| Rate for Payer: Anthem Medicaid |
$1,553.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3,219.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,219.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,863.16
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3,219.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,219.30
|
| 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 |
$4,185.09
|
| Rate for Payer: UHCCP Medicaid |
$1,034.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,569.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$3,219.30
|
|
|
ESPHG TOT W/THRCM
|
Facility
|
OP
|
$2,955.00
|
|
|
Service Code
|
HCPCS 43112
|
| Hospital Charge Code |
76101719
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$886.50 |
| 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 |
$2,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,570.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,038.95
|
| 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 |
$886.50 |
| 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 |
$2,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,570.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,038.95
|
| Rate for Payer: PHCS Commercial |
$2,836.80
|
| Rate for Payer: United Healthcare All Payer |
$2,600.40
|
|
