|
CYSTATIN C
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS 82610
|
| Hospital Charge Code |
30001875
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.03
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.56
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
CYSTATIN C
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS 82610
|
| Hospital Charge Code |
30001875
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem Medicaid |
$18.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.03
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.52
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Humana KY Medicaid |
$18.52
|
| Rate for Payer: Humana Medicare Advantage |
$18.52
|
| Rate for Payer: Kentucky WC Medicaid |
$18.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.56
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
CYSTECTOMY, PARTIAL; SIMPLE
|
Facility
|
IP
|
$2,350.00
|
|
|
Service Code
|
HCPCS 51550
|
| Hospital Charge Code |
76102062
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$305.50 |
| Max. Negotiated Rate |
$2,256.00 |
| Rate for Payer: Aetna Commercial |
$1,809.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,833.00
|
| Rate for Payer: Cash Price |
$1,175.00
|
| Rate for Payer: Cigna Commercial |
$1,950.50
|
| Rate for Payer: First Health Commercial |
$2,232.50
|
| Rate for Payer: Humana Commercial |
$1,997.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,927.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,734.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$705.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,068.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,762.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$470.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$305.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$728.50
|
| Rate for Payer: PHCS Commercial |
$2,256.00
|
| Rate for Payer: United Healthcare All Payer |
$2,068.00
|
|
|
CYSTECTOMY, PARTIAL; SIMPLE
|
Professional
|
Both
|
$2,350.00
|
|
|
Service Code
|
HCPCS 51550
|
| Hospital Charge Code |
76102062
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$736.48 |
| Max. Negotiated Rate |
$2,350.00 |
| Rate for Payer: Aetna Commercial |
$1,543.96
|
| Rate for Payer: Anthem Medicaid |
$736.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,350.00
|
| Rate for Payer: Cash Price |
$1,175.00
|
| Rate for Payer: Cash Price |
$1,175.00
|
| Rate for Payer: Cigna Commercial |
$1,384.28
|
| Rate for Payer: Healthspan PPO |
$1,234.53
|
| Rate for Payer: Humana Medicaid |
$736.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,315.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$751.21
|
| Rate for Payer: Molina Healthcare Passport |
$736.48
|
| Rate for Payer: Multiplan PHCS |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,645.00
|
| Rate for Payer: UHCCP Medicaid |
$822.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$743.84
|
|
|
CYSTECTOMY, PARTIAL; SIMPLE
|
Facility
|
OP
|
$2,350.00
|
|
|
Service Code
|
HCPCS 51550
|
| Hospital Charge Code |
76102062
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$305.50 |
| Max. Negotiated Rate |
$2,256.00 |
| Rate for Payer: Aetna Commercial |
$1,809.50
|
| Rate for Payer: Anthem Medicaid |
$808.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,833.00
|
| Rate for Payer: Cash Price |
$1,175.00
|
| Rate for Payer: Cigna Commercial |
$1,950.50
|
| Rate for Payer: First Health Commercial |
$2,232.50
|
| Rate for Payer: Humana Commercial |
$1,997.50
|
| Rate for Payer: Humana KY Medicaid |
$808.16
|
| Rate for Payer: Kentucky WC Medicaid |
$816.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,927.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,734.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$705.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$824.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,068.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,762.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$470.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$305.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$728.50
|
| Rate for Payer: PHCS Commercial |
$2,256.00
|
| Rate for Payer: United Healthcare All Payer |
$2,068.00
|
|
|
CYSTECTOMY, PARTIAL; SIMPLE(P
|
Professional
|
Both
|
$2,350.00
|
|
|
Service Code
|
HCPCS 51550
|
| Hospital Charge Code |
761P2062
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$736.48 |
| Max. Negotiated Rate |
$2,350.00 |
| Rate for Payer: Aetna Commercial |
$1,543.96
|
| Rate for Payer: Anthem Medicaid |
$736.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,350.00
|
| Rate for Payer: Cash Price |
$1,175.00
|
| Rate for Payer: Cash Price |
$1,175.00
|
| Rate for Payer: Cigna Commercial |
$1,384.28
|
| Rate for Payer: Healthspan PPO |
$1,234.53
|
| Rate for Payer: Humana Medicaid |
$736.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,315.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$751.21
|
| Rate for Payer: Molina Healthcare Passport |
$736.48
|
| Rate for Payer: Multiplan PHCS |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,645.00
|
| Rate for Payer: UHCCP Medicaid |
$822.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$743.84
|
|
|
CYSTO-CONRAY II 250ML
|
Facility
|
IP
|
$987.26
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
25003842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.34 |
| Max. Negotiated Rate |
$947.77 |
| Rate for Payer: Aetna Commercial |
$760.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$770.06
|
| Rate for Payer: Cash Price |
$493.63
|
| Rate for Payer: Cigna Commercial |
$819.43
|
| Rate for Payer: First Health Commercial |
$937.90
|
| Rate for Payer: Humana Commercial |
$839.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$809.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$728.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$296.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$868.79
|
| Rate for Payer: Ohio Health Group HMO |
$740.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$197.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$128.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$306.05
|
| Rate for Payer: PHCS Commercial |
$947.77
|
| Rate for Payer: United Healthcare All Payer |
$868.79
|
|
|
CYSTO-CONRAY II 250ML
|
Facility
|
OP
|
$987.26
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
25003842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.34 |
| Max. Negotiated Rate |
$947.77 |
| Rate for Payer: Aetna Commercial |
$760.19
|
| Rate for Payer: Anthem Medicaid |
$339.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$770.06
|
| Rate for Payer: Cash Price |
$493.63
|
| Rate for Payer: Cigna Commercial |
$819.43
|
| Rate for Payer: First Health Commercial |
$937.90
|
| Rate for Payer: Humana Commercial |
$839.17
|
| Rate for Payer: Humana KY Medicaid |
$339.52
|
| Rate for Payer: Kentucky WC Medicaid |
$342.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$809.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$728.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$296.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$346.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$868.79
|
| Rate for Payer: Ohio Health Group HMO |
$740.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$197.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$128.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$306.05
|
| Rate for Payer: PHCS Commercial |
$947.77
|
| Rate for Payer: United Healthcare All Payer |
$868.79
|
|
|
CYSTO FRAGMENT URETERAL STONE
|
Facility
|
IP
|
$7,535.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
76102101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$979.55 |
| Max. Negotiated Rate |
$7,233.60 |
| Rate for Payer: Aetna Commercial |
$5,801.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,877.30
|
| Rate for Payer: Cash Price |
$3,767.50
|
| Rate for Payer: Cigna Commercial |
$6,254.05
|
| Rate for Payer: First Health Commercial |
$7,158.25
|
| Rate for Payer: Humana Commercial |
$6,404.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,178.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,560.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,260.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,630.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,651.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,507.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$979.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,335.85
|
| Rate for Payer: PHCS Commercial |
$7,233.60
|
| Rate for Payer: United Healthcare All Payer |
$6,630.80
|
|
|
CYSTO FRAGMENT URETERAL STONE
|
Professional
|
Both
|
$7,535.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
76102101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.30 |
| Max. Negotiated Rate |
$7,535.00 |
| Rate for Payer: Aetna Commercial |
$535.17
|
| Rate for Payer: Anthem Medicaid |
$385.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,535.00
|
| Rate for Payer: Cash Price |
$3,767.50
|
| Rate for Payer: Cash Price |
$3,767.50
|
| Rate for Payer: Cigna Commercial |
$478.80
|
| Rate for Payer: Healthspan PPO |
$427.92
|
| Rate for Payer: Humana Medicaid |
$385.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$439.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$393.01
|
| Rate for Payer: Molina Healthcare Passport |
$385.30
|
| Rate for Payer: Multiplan PHCS |
$4,521.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,274.50
|
| Rate for Payer: UHCCP Medicaid |
$2,637.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$389.15
|
|
|
CYSTO FRAGMENT URETERAL STONE
|
Facility
|
OP
|
$7,535.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
76102101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$979.55 |
| Max. Negotiated Rate |
$7,233.60 |
| Rate for Payer: Aetna Commercial |
$5,801.95
|
| Rate for Payer: Anthem Medicaid |
$2,591.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,474.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,877.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,264.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,040.63
|
| Rate for Payer: Cash Price |
$3,767.50
|
| Rate for Payer: Cash Price |
$3,767.50
|
| Rate for Payer: Cigna Commercial |
$6,254.05
|
| Rate for Payer: First Health Commercial |
$7,158.25
|
| Rate for Payer: Humana Commercial |
$6,404.75
|
| Rate for Payer: Humana KY Medicaid |
$2,591.29
|
| Rate for Payer: Humana Medicare Advantage |
$4,474.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,617.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,178.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,560.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,369.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,643.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,630.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,651.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,507.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$979.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,335.85
|
| Rate for Payer: PHCS Commercial |
$7,233.60
|
| Rate for Payer: United Healthcare All Payer |
$6,630.80
|
|
|
CYSTO FRAGMENT URETERAL STON(P
|
Professional
|
Both
|
$1,300.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
761P2101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.30 |
| Max. Negotiated Rate |
$1,300.00 |
| Rate for Payer: Aetna Commercial |
$535.17
|
| Rate for Payer: Anthem Medicaid |
$385.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,300.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$478.80
|
| Rate for Payer: Healthspan PPO |
$427.92
|
| Rate for Payer: Humana Medicaid |
$385.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$439.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$393.01
|
| Rate for Payer: Molina Healthcare Passport |
$385.30
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$389.15
|
|
|
CYSTO FRAGMENT URETERAL STON(T
|
Facility
|
IP
|
$6,235.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
761T2101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$810.55 |
| Max. Negotiated Rate |
$5,985.60 |
| Rate for Payer: Aetna Commercial |
$4,800.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,863.30
|
| Rate for Payer: Cash Price |
$3,117.50
|
| Rate for Payer: Cigna Commercial |
$5,175.05
|
| Rate for Payer: First Health Commercial |
$5,923.25
|
| Rate for Payer: Humana Commercial |
$5,299.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,112.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,601.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,870.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,486.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,247.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$810.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.85
|
| Rate for Payer: PHCS Commercial |
$5,985.60
|
| Rate for Payer: United Healthcare All Payer |
$5,486.80
|
|
|
CYSTO FRAGMENT URETERAL STON(T
|
Facility
|
OP
|
$6,235.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
761T2101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$810.55 |
| Max. Negotiated Rate |
$6,264.36 |
| Rate for Payer: Aetna Commercial |
$4,800.95
|
| Rate for Payer: Anthem Medicaid |
$2,144.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,474.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,863.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,264.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,040.63
|
| Rate for Payer: Cash Price |
$3,117.50
|
| Rate for Payer: Cash Price |
$3,117.50
|
| Rate for Payer: Cigna Commercial |
$5,175.05
|
| Rate for Payer: First Health Commercial |
$5,923.25
|
| Rate for Payer: Humana Commercial |
$5,299.75
|
| Rate for Payer: Humana KY Medicaid |
$2,144.22
|
| Rate for Payer: Humana Medicare Advantage |
$4,474.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,166.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,112.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,601.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,369.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,187.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,486.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,247.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$810.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.85
|
| Rate for Payer: PHCS Commercial |
$5,985.60
|
| Rate for Payer: United Healthcare All Payer |
$5,486.80
|
|
|
CYSTOGRAFIN-DILUTE 1ML (300ML)
|
Facility
|
IP
|
$1,187.37
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
25004249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.36 |
| Max. Negotiated Rate |
$1,139.88 |
| Rate for Payer: Aetna Commercial |
$914.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$926.15
|
| Rate for Payer: Cash Price |
$593.68
|
| Rate for Payer: Cigna Commercial |
$985.52
|
| Rate for Payer: First Health Commercial |
$1,128.00
|
| Rate for Payer: Humana Commercial |
$1,009.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$973.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$876.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$356.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,044.89
|
| Rate for Payer: Ohio Health Group HMO |
$890.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$237.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.08
|
| Rate for Payer: PHCS Commercial |
$1,139.88
|
| Rate for Payer: United Healthcare All Payer |
$1,044.89
|
|
|
CYSTOGRAFIN-DILUTE 1ML (300ML)
|
Facility
|
OP
|
$1,187.37
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
25004249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.36 |
| Max. Negotiated Rate |
$1,139.88 |
| Rate for Payer: Aetna Commercial |
$914.27
|
| Rate for Payer: Anthem Medicaid |
$408.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$926.15
|
| Rate for Payer: Cash Price |
$593.68
|
| Rate for Payer: Cigna Commercial |
$985.52
|
| Rate for Payer: First Health Commercial |
$1,128.00
|
| Rate for Payer: Humana Commercial |
$1,009.26
|
| Rate for Payer: Humana KY Medicaid |
$408.34
|
| Rate for Payer: Kentucky WC Medicaid |
$412.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$973.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$876.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$356.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$416.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,044.89
|
| Rate for Payer: Ohio Health Group HMO |
$890.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$237.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.08
|
| Rate for Payer: PHCS Commercial |
$1,139.88
|
| Rate for Payer: United Healthcare All Payer |
$1,044.89
|
|
|
CYSTOGRAM STATIC 3V
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
32000146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$78.52 |
| Max. Negotiated Rate |
$579.84 |
| Rate for Payer: Aetna Commercial |
$465.08
|
| Rate for Payer: Anthem Medicaid |
$207.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$332.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$465.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$448.96
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$501.32
|
| Rate for Payer: First Health Commercial |
$573.80
|
| Rate for Payer: Humana Commercial |
$513.40
|
| Rate for Payer: Humana KY Medicaid |
$207.72
|
| Rate for Payer: Humana Medicare Advantage |
$332.56
|
| Rate for Payer: Kentucky WC Medicaid |
$209.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$495.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$445.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$211.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$531.52
|
| Rate for Payer: Ohio Health Group HMO |
$453.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$187.24
|
| Rate for Payer: PHCS Commercial |
$579.84
|
| Rate for Payer: United Healthcare All Payer |
$531.52
|
|
|
CYSTOGRAM STATIC 3V
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
32000146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$78.52 |
| Max. Negotiated Rate |
$579.84 |
| Rate for Payer: Aetna Commercial |
$465.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.12
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$501.32
|
| Rate for Payer: First Health Commercial |
$573.80
|
| Rate for Payer: Humana Commercial |
$513.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$495.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$445.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$181.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$531.52
|
| Rate for Payer: Ohio Health Group HMO |
$453.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$187.24
|
| Rate for Payer: PHCS Commercial |
$579.84
|
| Rate for Payer: United Healthcare All Payer |
$531.52
|
|
|
CYSTOGRAM STATIC 3V
|
Professional
|
Both
|
$604.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
32000146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$117.84
|
| Rate for Payer: Anthem Medicaid |
$42.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$604.00
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$94.99
|
| Rate for Payer: Healthspan PPO |
$110.42
|
| Rate for Payer: Humana Medicaid |
$42.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.27
|
| Rate for Payer: Molina Healthcare Passport |
$42.42
|
| Rate for Payer: Multiplan PHCS |
$362.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$422.80
|
| Rate for Payer: UHCCP Medicaid |
$211.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.84
|
|
|
CYSTOGRAM STATIC 3V(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
320P0146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$117.84 |
| Rate for Payer: Aetna Commercial |
$117.84
|
| Rate for Payer: Anthem Medicaid |
$42.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$94.99
|
| Rate for Payer: Healthspan PPO |
$110.42
|
| Rate for Payer: Humana Medicaid |
$42.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.27
|
| Rate for Payer: Molina Healthcare Passport |
$42.42
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.84
|
|
|
CYSTOGRAM STATIC 3V(T
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
320T0146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$68.77 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$407.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.62
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$439.07
|
| Rate for Payer: First Health Commercial |
$502.55
|
| Rate for Payer: Humana Commercial |
$449.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.52
|
| Rate for Payer: Ohio Health Group HMO |
$396.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.99
|
| Rate for Payer: PHCS Commercial |
$507.84
|
| Rate for Payer: United Healthcare All Payer |
$465.52
|
|
|
CYSTOGRAM STATIC 3V(T
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
320T0146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$68.77 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$407.33
|
| Rate for Payer: Anthem Medicaid |
$181.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$332.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$465.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$448.96
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$439.07
|
| Rate for Payer: First Health Commercial |
$502.55
|
| Rate for Payer: Humana Commercial |
$449.65
|
| Rate for Payer: Humana KY Medicaid |
$181.92
|
| Rate for Payer: Humana Medicare Advantage |
$332.56
|
| Rate for Payer: Kentucky WC Medicaid |
$183.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.52
|
| Rate for Payer: Ohio Health Group HMO |
$396.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.99
|
| Rate for Payer: PHCS Commercial |
$507.84
|
| Rate for Payer: United Healthcare All Payer |
$465.52
|
|
|
CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION
|
Facility
|
OP
|
$6,264.36
|
|
|
Service Code
|
CPT 51050
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,474.54 |
| Max. Negotiated Rate |
$6,264.36 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,474.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,264.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,040.63
|
| Rate for Payer: Humana Medicare Advantage |
$4,474.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,369.45
|
|
|
CYSTO MANJ W/O RMVL URT STONE
|
Facility
|
IP
|
$6,328.84
|
|
|
Service Code
|
HCPCS 52330
|
| Hospital Charge Code |
76102102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.75 |
| Max. Negotiated Rate |
$6,075.69 |
| Rate for Payer: Aetna Commercial |
$4,873.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,936.50
|
| Rate for Payer: Cash Price |
$3,164.42
|
| Rate for Payer: Cigna Commercial |
$5,252.94
|
| Rate for Payer: First Health Commercial |
$6,012.40
|
| Rate for Payer: Humana Commercial |
$5,379.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,189.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,670.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,898.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,569.38
|
| Rate for Payer: Ohio Health Group HMO |
$4,746.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,265.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$822.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,961.94
|
| Rate for Payer: PHCS Commercial |
$6,075.69
|
| Rate for Payer: United Healthcare All Payer |
$5,569.38
|
|
|
CYSTO MANJ W/O RMVL URT STONE
|
Professional
|
Both
|
$6,328.84
|
|
|
Service Code
|
HCPCS 52330
|
| Hospital Charge Code |
76102102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$6,328.84 |
| Rate for Payer: Aetna Commercial |
$440.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.03
|
| Rate for Payer: Anthem Medicaid |
$249.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,328.84
|
| Rate for Payer: Cash Price |
$3,164.42
|
| Rate for Payer: Cash Price |
$3,164.42
|
| Rate for Payer: Cigna Commercial |
$393.14
|
| Rate for Payer: Healthspan PPO |
$969.08
|
| Rate for Payer: Humana Medicaid |
$249.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$361.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.46
|
| Rate for Payer: Molina Healthcare Passport |
$249.47
|
| Rate for Payer: Multiplan PHCS |
$3,797.30
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,430.19
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$251.96
|
|
