|
CYSTO MANJ W/O RMVL URT STONE
|
Facility
|
OP
|
$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 Medicaid |
$2,176.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,936.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Cash Price |
$3,164.42
|
| 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: Humana KY Medicaid |
$2,176.49
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,198.64
|
| 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 |
$3,617.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,220.16
|
| 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 STON(P
|
Professional
|
Both
|
$1,975.00
|
|
|
Service Code
|
HCPCS 52330
|
| Hospital Charge Code |
761P2102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$1,975.00 |
| 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 |
$1,975.00
|
| Rate for Payer: Cash Price |
$987.50
|
| Rate for Payer: Cash Price |
$987.50
|
| 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 |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,382.50
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$251.96
|
|
|
CYSTO MANJ W/O RMVL URT STON(T
|
Facility
|
OP
|
$4,353.84
|
|
|
Service Code
|
HCPCS 52330
|
| Hospital Charge Code |
761T2102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$566.00 |
| Max. Negotiated Rate |
$4,220.54 |
| Rate for Payer: Aetna Commercial |
$3,352.46
|
| Rate for Payer: Anthem Medicaid |
$1,497.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,396.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Cash Price |
$2,176.92
|
| Rate for Payer: Cash Price |
$2,176.92
|
| Rate for Payer: Cigna Commercial |
$3,613.69
|
| Rate for Payer: First Health Commercial |
$4,136.15
|
| Rate for Payer: Humana Commercial |
$3,700.76
|
| Rate for Payer: Humana KY Medicaid |
$1,497.29
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,512.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,570.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,213.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,527.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,831.38
|
| Rate for Payer: Ohio Health Group HMO |
$3,265.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,349.69
|
| Rate for Payer: PHCS Commercial |
$4,179.69
|
| Rate for Payer: United Healthcare All Payer |
$3,831.38
|
|
|
CYSTO MANJ W/O RMVL URT STON(T
|
Facility
|
IP
|
$4,353.84
|
|
|
Service Code
|
HCPCS 52330
|
| Hospital Charge Code |
761T2102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$566.00 |
| Max. Negotiated Rate |
$4,179.69 |
| Rate for Payer: Aetna Commercial |
$3,352.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,396.00
|
| Rate for Payer: Cash Price |
$2,176.92
|
| Rate for Payer: Cigna Commercial |
$3,613.69
|
| Rate for Payer: First Health Commercial |
$4,136.15
|
| Rate for Payer: Humana Commercial |
$3,700.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,570.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,213.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,306.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,831.38
|
| Rate for Payer: Ohio Health Group HMO |
$3,265.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,349.69
|
| Rate for Payer: PHCS Commercial |
$4,179.69
|
| Rate for Payer: United Healthcare All Payer |
$3,831.38
|
|
|
CYSTOMETROGRAM W/UP
|
Facility
|
OP
|
$1,410.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
76102785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.30 |
| Max. Negotiated Rate |
$1,353.60 |
| Rate for Payer: Aetna Commercial |
$1,085.70
|
| Rate for Payer: Anthem Medicaid |
$484.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,099.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cigna Commercial |
$1,170.30
|
| Rate for Payer: First Health Commercial |
$1,339.50
|
| Rate for Payer: Humana Commercial |
$1,198.50
|
| Rate for Payer: Humana KY Medicaid |
$484.90
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$489.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,156.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,040.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$494.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,240.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,057.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$437.10
|
| Rate for Payer: PHCS Commercial |
$1,353.60
|
| Rate for Payer: United Healthcare All Payer |
$1,240.80
|
|
|
CYSTOMETROGRAM W/UP
|
Facility
|
IP
|
$1,410.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
76102785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.30 |
| Max. Negotiated Rate |
$1,353.60 |
| Rate for Payer: Aetna Commercial |
$1,085.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,099.80
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cigna Commercial |
$1,170.30
|
| Rate for Payer: First Health Commercial |
$1,339.50
|
| Rate for Payer: Humana Commercial |
$1,198.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,156.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,040.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$423.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,240.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,057.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$437.10
|
| Rate for Payer: PHCS Commercial |
$1,353.60
|
| Rate for Payer: United Healthcare All Payer |
$1,240.80
|
|
|
CYSTOMETROGRAM W/UP
|
Professional
|
Both
|
$1,410.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
76102785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.42 |
| Max. Negotiated Rate |
$1,410.00 |
| Rate for Payer: Aetna Commercial |
$443.54
|
| Rate for Payer: Anthem Medicaid |
$245.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,410.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cigna Commercial |
$454.02
|
| Rate for Payer: Healthspan PPO |
$278.57
|
| Rate for Payer: Humana Medicaid |
$245.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$145.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$250.18
|
| Rate for Payer: Molina Healthcare Passport |
$245.27
|
| Rate for Payer: Multiplan PHCS |
$846.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$987.00
|
| Rate for Payer: UHCCP Medicaid |
$493.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$247.72
|
|
|
CYSTOMETROGRAM W/UP (P
|
Professional
|
Both
|
$130.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
761P2785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$454.02 |
| Rate for Payer: Aetna Commercial |
$443.54
|
| Rate for Payer: Anthem Medicaid |
$245.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$454.02
|
| Rate for Payer: Healthspan PPO |
$278.57
|
| Rate for Payer: Humana Medicaid |
$245.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$145.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$250.18
|
| Rate for Payer: Molina Healthcare Passport |
$245.27
|
| Rate for Payer: Multiplan PHCS |
$78.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$91.00
|
| Rate for Payer: UHCCP Medicaid |
$45.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$247.72
|
|
|
CYSTOMETROGRAM W/UP (T
|
Facility
|
IP
|
$1,280.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
761T2785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.40 |
| Max. Negotiated Rate |
$1,228.80 |
| Rate for Payer: Aetna Commercial |
$985.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$998.40
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cigna Commercial |
$1,062.40
|
| Rate for Payer: First Health Commercial |
$1,216.00
|
| Rate for Payer: Humana Commercial |
$1,088.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,049.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$944.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$384.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,126.40
|
| Rate for Payer: Ohio Health Group HMO |
$960.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.80
|
| Rate for Payer: PHCS Commercial |
$1,228.80
|
| Rate for Payer: United Healthcare All Payer |
$1,126.40
|
|
|
CYSTOMETROGRAM W/UP (T
|
Facility
|
OP
|
$1,280.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
761T2785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.40 |
| Max. Negotiated Rate |
$1,228.80 |
| Rate for Payer: Aetna Commercial |
$985.60
|
| Rate for Payer: Anthem Medicaid |
$440.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$998.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cigna Commercial |
$1,062.40
|
| Rate for Payer: First Health Commercial |
$1,216.00
|
| Rate for Payer: Humana Commercial |
$1,088.00
|
| Rate for Payer: Humana KY Medicaid |
$440.19
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$444.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,049.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$944.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$449.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,126.40
|
| Rate for Payer: Ohio Health Group HMO |
$960.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.80
|
| Rate for Payer: PHCS Commercial |
$1,228.80
|
| Rate for Payer: United Healthcare All Payer |
$1,126.40
|
|
|
CYSTOMETROGRAM W/VP
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
76102786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.25 |
| Max. Negotiated Rate |
$1,464.00 |
| Rate for Payer: Aetna Commercial |
$1,174.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,189.50
|
| Rate for Payer: Cash Price |
$762.50
|
| Rate for Payer: Cigna Commercial |
$1,265.75
|
| Rate for Payer: First Health Commercial |
$1,448.75
|
| Rate for Payer: Humana Commercial |
$1,296.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,250.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,125.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$457.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,342.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.75
|
| Rate for Payer: PHCS Commercial |
$1,464.00
|
| Rate for Payer: United Healthcare All Payer |
$1,342.00
|
|
|
CYSTOMETROGRAM W/VP
|
Professional
|
Both
|
$1,525.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
76102786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.92 |
| Max. Negotiated Rate |
$1,525.00 |
| Rate for Payer: Aetna Commercial |
$442.64
|
| Rate for Payer: Anthem Medicaid |
$244.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,525.00
|
| Rate for Payer: Cash Price |
$762.50
|
| Rate for Payer: Cash Price |
$762.50
|
| Rate for Payer: Cigna Commercial |
$453.43
|
| Rate for Payer: Healthspan PPO |
$278.00
|
| Rate for Payer: Humana Medicaid |
$244.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$141.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$249.26
|
| Rate for Payer: Molina Healthcare Passport |
$244.37
|
| Rate for Payer: Multiplan PHCS |
$915.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,067.50
|
| Rate for Payer: UHCCP Medicaid |
$533.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$246.81
|
|
|
CYSTOMETROGRAM W/VP
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
76102786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.25 |
| Max. Negotiated Rate |
$1,464.00 |
| Rate for Payer: Aetna Commercial |
$1,174.25
|
| Rate for Payer: Anthem Medicaid |
$524.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,189.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$762.50
|
| Rate for Payer: Cash Price |
$762.50
|
| Rate for Payer: Cigna Commercial |
$1,265.75
|
| Rate for Payer: First Health Commercial |
$1,448.75
|
| Rate for Payer: Humana Commercial |
$1,296.25
|
| Rate for Payer: Humana KY Medicaid |
$524.45
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$529.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,250.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,125.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,342.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.75
|
| Rate for Payer: PHCS Commercial |
$1,464.00
|
| Rate for Payer: United Healthcare All Payer |
$1,342.00
|
|
|
CYSTOMETROGRAM W/VP (P
|
Professional
|
Both
|
$130.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
761P2786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$453.43 |
| Rate for Payer: Aetna Commercial |
$442.64
|
| Rate for Payer: Anthem Medicaid |
$244.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$453.43
|
| Rate for Payer: Healthspan PPO |
$278.00
|
| Rate for Payer: Humana Medicaid |
$244.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$141.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$249.26
|
| Rate for Payer: Molina Healthcare Passport |
$244.37
|
| Rate for Payer: Multiplan PHCS |
$78.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$91.00
|
| Rate for Payer: UHCCP Medicaid |
$45.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$246.81
|
|
|
CYSTOMETROGRAM W/VP (T
|
Facility
|
OP
|
$1,395.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
761T2786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.35 |
| Max. Negotiated Rate |
$1,339.20 |
| Rate for Payer: Aetna Commercial |
$1,074.15
|
| Rate for Payer: Anthem Medicaid |
$479.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,088.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$697.50
|
| Rate for Payer: Cash Price |
$697.50
|
| Rate for Payer: Cigna Commercial |
$1,157.85
|
| Rate for Payer: First Health Commercial |
$1,325.25
|
| Rate for Payer: Humana Commercial |
$1,185.75
|
| Rate for Payer: Humana KY Medicaid |
$479.74
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$484.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,143.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,029.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$489.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,227.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,046.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$181.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$432.45
|
| Rate for Payer: PHCS Commercial |
$1,339.20
|
| Rate for Payer: United Healthcare All Payer |
$1,227.60
|
|
|
CYSTOMETROGRAM W/VP (T
|
Facility
|
IP
|
$1,395.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
761T2786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.35 |
| Max. Negotiated Rate |
$1,339.20 |
| Rate for Payer: Aetna Commercial |
$1,074.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,088.10
|
| Rate for Payer: Cash Price |
$697.50
|
| Rate for Payer: Cigna Commercial |
$1,157.85
|
| Rate for Payer: First Health Commercial |
$1,325.25
|
| Rate for Payer: Humana Commercial |
$1,185.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,143.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,029.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$418.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,227.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,046.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$181.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$432.45
|
| Rate for Payer: PHCS Commercial |
$1,339.20
|
| Rate for Payer: United Healthcare All Payer |
$1,227.60
|
|
|
CYSTOMETROGRAM W/VP&UP
|
Professional
|
Both
|
$1,331.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
32000263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$171.33 |
| Max. Negotiated Rate |
$1,331.00 |
| Rate for Payer: Aetna Commercial |
$476.84
|
| Rate for Payer: Anthem Medicaid |
$267.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,331.00
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cigna Commercial |
$488.62
|
| Rate for Payer: Healthspan PPO |
$299.97
|
| Rate for Payer: Humana Medicaid |
$267.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$171.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$272.40
|
| Rate for Payer: Molina Healthcare Passport |
$267.06
|
| Rate for Payer: Multiplan PHCS |
$798.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$931.70
|
| Rate for Payer: UHCCP Medicaid |
$465.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$269.73
|
|
|
CYSTOMETROGRAM W/VP&UP
|
Facility
|
IP
|
$1,331.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
32000263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$173.03 |
| Max. Negotiated Rate |
$1,277.76 |
| Rate for Payer: Aetna Commercial |
$1,024.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,038.18
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cigna Commercial |
$1,104.73
|
| Rate for Payer: First Health Commercial |
$1,264.45
|
| Rate for Payer: Humana Commercial |
$1,131.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,091.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$982.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,171.28
|
| Rate for Payer: Ohio Health Group HMO |
$998.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$266.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$412.61
|
| Rate for Payer: PHCS Commercial |
$1,277.76
|
| Rate for Payer: United Healthcare All Payer |
$1,171.28
|
|
|
CYSTOMETROGRAM W/VP&UP
|
Facility
|
OP
|
$1,331.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
32000263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$173.03 |
| Max. Negotiated Rate |
$1,277.76 |
| Rate for Payer: Aetna Commercial |
$1,024.87
|
| Rate for Payer: Anthem Medicaid |
$457.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,038.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cigna Commercial |
$1,104.73
|
| Rate for Payer: First Health Commercial |
$1,264.45
|
| Rate for Payer: Humana Commercial |
$1,131.35
|
| Rate for Payer: Humana KY Medicaid |
$457.73
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$462.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,091.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$982.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$466.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,171.28
|
| Rate for Payer: Ohio Health Group HMO |
$998.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$266.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$412.61
|
| Rate for Payer: PHCS Commercial |
$1,277.76
|
| Rate for Payer: United Healthcare All Payer |
$1,171.28
|
|
|
CYSTOMETROGRAM W/VP&UP(P
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
320P0263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$488.62 |
| Rate for Payer: Aetna Commercial |
$476.84
|
| Rate for Payer: Anthem Medicaid |
$267.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$325.00
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$488.62
|
| Rate for Payer: Healthspan PPO |
$299.97
|
| Rate for Payer: Humana Medicaid |
$267.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$171.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$272.40
|
| Rate for Payer: Molina Healthcare Passport |
$267.06
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$269.73
|
|
|
CYSTOMETROGRAM W/VP&UP(T
|
Facility
|
IP
|
$1,006.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
320T0263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$130.78 |
| Max. Negotiated Rate |
$965.76 |
| Rate for Payer: Aetna Commercial |
$774.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$784.68
|
| Rate for Payer: Cash Price |
$503.00
|
| Rate for Payer: Cigna Commercial |
$834.98
|
| Rate for Payer: First Health Commercial |
$955.70
|
| Rate for Payer: Humana Commercial |
$855.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$824.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$742.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$301.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$885.28
|
| Rate for Payer: Ohio Health Group HMO |
$754.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$311.86
|
| Rate for Payer: PHCS Commercial |
$965.76
|
| Rate for Payer: United Healthcare All Payer |
$885.28
|
|
|
CYSTOMETROGRAM W/VP&UP(T
|
Facility
|
OP
|
$1,006.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
320T0263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$130.78 |
| Max. Negotiated Rate |
$965.76 |
| Rate for Payer: Aetna Commercial |
$774.62
|
| Rate for Payer: Anthem Medicaid |
$345.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$784.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$503.00
|
| Rate for Payer: Cash Price |
$503.00
|
| Rate for Payer: Cigna Commercial |
$834.98
|
| Rate for Payer: First Health Commercial |
$955.70
|
| Rate for Payer: Humana Commercial |
$855.10
|
| Rate for Payer: Humana KY Medicaid |
$345.96
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$349.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$824.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$742.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$352.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$885.28
|
| Rate for Payer: Ohio Health Group HMO |
$754.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$311.86
|
| Rate for Payer: PHCS Commercial |
$965.76
|
| Rate for Payer: United Healthcare All Payer |
$885.28
|
|
|
CYSTO/PYELO BX/FULG PEL LSN
|
Facility
|
OP
|
$7,086.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
76102109
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$921.18 |
| Max. Negotiated Rate |
$6,802.56 |
| Rate for Payer: Ohio Health Choice Commercial |
$6,235.68
|
| Rate for Payer: Aetna Commercial |
$5,456.22
|
| Rate for Payer: Anthem Medicaid |
$2,436.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,474.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,527.08
|
| 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 |
$3,543.00
|
| Rate for Payer: Cash Price |
$3,543.00
|
| Rate for Payer: Cigna Commercial |
$5,881.38
|
| Rate for Payer: First Health Commercial |
$6,731.70
|
| Rate for Payer: Humana Commercial |
$6,023.10
|
| Rate for Payer: Humana KY Medicaid |
$2,436.88
|
| Rate for Payer: Humana Medicare Advantage |
$4,474.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,461.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,810.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,229.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,369.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,485.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,314.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,417.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$921.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,196.66
|
| Rate for Payer: PHCS Commercial |
$6,802.56
|
| Rate for Payer: United Healthcare All Payer |
$6,235.68
|
|
|
CYSTO/PYELO BX/FULG PEL LSN
|
Facility
|
IP
|
$7,086.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
76102109
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$921.18 |
| Max. Negotiated Rate |
$6,802.56 |
| Rate for Payer: Aetna Commercial |
$5,456.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,527.08
|
| Rate for Payer: Cash Price |
$3,543.00
|
| Rate for Payer: Cigna Commercial |
$5,881.38
|
| Rate for Payer: First Health Commercial |
$6,731.70
|
| Rate for Payer: Humana Commercial |
$6,023.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,810.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,229.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,125.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,235.68
|
| Rate for Payer: Ohio Health Group HMO |
$5,314.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,417.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$921.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,196.66
|
| Rate for Payer: PHCS Commercial |
$6,802.56
|
| Rate for Payer: United Healthcare All Payer |
$6,235.68
|
|
|
CYSTO/PYELO BX/FULG PEL LSN
|
Professional
|
Both
|
$7,086.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
76102109
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$310.28 |
| Max. Negotiated Rate |
$7,086.00 |
| Rate for Payer: Aetna Commercial |
$652.33
|
| Rate for Payer: Anthem Medicaid |
$310.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,086.00
|
| Rate for Payer: Cash Price |
$3,543.00
|
| Rate for Payer: Cash Price |
$3,543.00
|
| Rate for Payer: Cigna Commercial |
$580.66
|
| Rate for Payer: Healthspan PPO |
$521.60
|
| Rate for Payer: Humana Medicaid |
$310.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$537.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$316.49
|
| Rate for Payer: Molina Healthcare Passport |
$310.28
|
| Rate for Payer: Multiplan PHCS |
$4,251.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,960.20
|
| Rate for Payer: UHCCP Medicaid |
$2,480.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$313.38
|
|
