|
CYRAMZA 5MG [500 MG/50ML)VIAL
|
Facility
|
IP
|
$40,094.51
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002674
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,028.35 |
| Max. Negotiated Rate |
$38,490.73 |
| Rate for Payer: Aetna Commercial |
$30,872.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,273.72
|
| Rate for Payer: Cash Price |
$20,047.26
|
| Rate for Payer: Cigna Commercial |
$33,278.44
|
| Rate for Payer: First Health Commercial |
$38,089.78
|
| Rate for Payer: Humana Commercial |
$34,080.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,877.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,589.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,028.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,283.17
|
| Rate for Payer: Ohio Health Group HMO |
$30,070.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,075.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34,882.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,665.21
|
| Rate for Payer: PHCS Commercial |
$38,490.73
|
| Rate for Payer: United Healthcare All Payer |
$35,283.17
|
|
|
CYRAMZA 5MG [500 MG/50ML)VIAL
|
Facility
|
OP
|
$40,094.51
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002674
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.45 |
| Max. Negotiated Rate |
$38,490.73 |
| Rate for Payer: Aetna Commercial |
$30,872.77
|
| Rate for Payer: Anthem Medicaid |
$13,788.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$74.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,273.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$104.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$100.51
|
| Rate for Payer: Cash Price |
$20,047.26
|
| Rate for Payer: Cash Price |
$20,047.26
|
| Rate for Payer: Cigna Commercial |
$33,278.44
|
| Rate for Payer: First Health Commercial |
$38,089.78
|
| Rate for Payer: Humana Commercial |
$34,080.33
|
| Rate for Payer: Humana KY Medicaid |
$13,788.50
|
| Rate for Payer: Humana Medicare Advantage |
$74.45
|
| Rate for Payer: Kentucky WC Medicaid |
$13,928.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,877.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,589.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$89.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,065.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,283.17
|
| Rate for Payer: Ohio Health Group HMO |
$30,070.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,075.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34,882.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,665.21
|
| Rate for Payer: PHCS Commercial |
$38,490.73
|
| Rate for Payer: United Healthcare All Payer |
$35,283.17
|
|
|
CYST ASPIRATION EA ADDTL
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
76100275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.60 |
| Max. Negotiated Rate |
$558.72 |
| Rate for Payer: Aetna Commercial |
$448.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$453.96
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$483.06
|
| Rate for Payer: First Health Commercial |
$552.90
|
| Rate for Payer: Humana Commercial |
$494.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$477.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$429.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$512.16
|
| Rate for Payer: Ohio Health Group HMO |
$436.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$506.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$401.58
|
| Rate for Payer: PHCS Commercial |
$558.72
|
| Rate for Payer: United Healthcare All Payer |
$512.16
|
|
|
CYST ASPIRATION EA ADDTL
|
Professional
|
Both
|
$582.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
76100275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$349.20 |
| Rate for Payer: Aetna Commercial |
$35.12
|
| Rate for Payer: Ambetter Exchange |
$19.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.21
|
| Rate for Payer: Anthem Medicaid |
$19.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$19.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$19.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.21
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$38.48
|
| Rate for Payer: Healthspan PPO |
$32.79
|
| Rate for Payer: Humana Medicaid |
$19.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$19.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.38
|
| Rate for Payer: Molina Healthcare Passport |
$19.98
|
| Rate for Payer: Multiplan PHCS |
$349.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.14
|
| Rate for Payer: UHCCP Medicaid |
$17.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$19.34
|
|
|
CYST ASPIRATION EA ADDTL
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
76100275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.60 |
| Max. Negotiated Rate |
$558.72 |
| Rate for Payer: Aetna Commercial |
$448.14
|
| Rate for Payer: Anthem Medicaid |
$200.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$453.96
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$483.06
|
| Rate for Payer: First Health Commercial |
$552.90
|
| Rate for Payer: Humana Commercial |
$494.70
|
| Rate for Payer: Humana KY Medicaid |
$200.15
|
| Rate for Payer: Kentucky WC Medicaid |
$202.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$477.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$429.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$204.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$512.16
|
| Rate for Payer: Ohio Health Group HMO |
$436.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$506.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$401.58
|
| Rate for Payer: PHCS Commercial |
$558.72
|
| Rate for Payer: United Healthcare All Payer |
$512.16
|
|
|
CYST ASPIRATION EA ADDTL(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
761P0275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$35.12
|
| Rate for Payer: Ambetter Exchange |
$19.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.21
|
| Rate for Payer: Anthem Medicaid |
$19.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$19.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$19.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.21
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$38.48
|
| Rate for Payer: Healthspan PPO |
$32.79
|
| Rate for Payer: Humana Medicaid |
$19.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$19.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.38
|
| Rate for Payer: Molina Healthcare Passport |
$19.98
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.14
|
| Rate for Payer: UHCCP Medicaid |
$17.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$19.34
|
|
|
CYST ASPIRATION EA ADDTL(T
|
Facility
|
IP
|
$482.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
761T0275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.60 |
| Max. Negotiated Rate |
$462.72 |
| Rate for Payer: Aetna Commercial |
$371.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$375.96
|
| Rate for Payer: Cash Price |
$241.00
|
| Rate for Payer: Cigna Commercial |
$400.06
|
| Rate for Payer: First Health Commercial |
$457.90
|
| Rate for Payer: Humana Commercial |
$409.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$395.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$355.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$424.16
|
| Rate for Payer: Ohio Health Group HMO |
$361.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$419.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$332.58
|
| Rate for Payer: PHCS Commercial |
$462.72
|
| Rate for Payer: United Healthcare All Payer |
$424.16
|
|
|
CYST ASPIRATION EA ADDTL(T
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
761T0275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.60 |
| Max. Negotiated Rate |
$462.72 |
| Rate for Payer: Aetna Commercial |
$371.14
|
| Rate for Payer: Anthem Medicaid |
$165.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$375.96
|
| Rate for Payer: Cash Price |
$241.00
|
| Rate for Payer: Cigna Commercial |
$400.06
|
| Rate for Payer: First Health Commercial |
$457.90
|
| Rate for Payer: Humana Commercial |
$409.70
|
| Rate for Payer: Humana KY Medicaid |
$165.76
|
| Rate for Payer: Kentucky WC Medicaid |
$167.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$395.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$355.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$169.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$424.16
|
| Rate for Payer: Ohio Health Group HMO |
$361.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$419.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$332.58
|
| Rate for Payer: PHCS Commercial |
$462.72
|
| Rate for Payer: United Healthcare All Payer |
$424.16
|
|
|
CYST ASPIRATION U/S GUIDANCE
|
Facility
|
IP
|
$1,475.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$442.50 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$1,135.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,150.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,224.25
|
| Rate for Payer: First Health Commercial |
$1,401.25
|
| Rate for Payer: Humana Commercial |
$1,253.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,209.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,088.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,298.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,283.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,017.75
|
| Rate for Payer: PHCS Commercial |
$1,416.00
|
| Rate for Payer: United Healthcare All Payer |
$1,298.00
|
|
|
CYST ASPIRATION U/S GUIDANCE
|
Professional
|
Both
|
$1,475.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$885.00 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Ambetter Exchange |
$54.24
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$54.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$54.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.09
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$244.99
|
| Rate for Payer: Healthspan PPO |
$260.56
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$54.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$885.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.51
|
| Rate for Payer: UHCCP Medicaid |
$516.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$54.24
|
|
|
CYST ASPIRATION U/S GUIDANCE
|
Facility
|
OP
|
$1,475.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$442.50 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$1,135.75
|
| Rate for Payer: Anthem Medicaid |
$507.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,150.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,224.25
|
| Rate for Payer: First Health Commercial |
$1,401.25
|
| Rate for Payer: Humana Commercial |
$1,253.75
|
| Rate for Payer: Humana KY Medicaid |
$507.25
|
| Rate for Payer: Kentucky WC Medicaid |
$512.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,209.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,088.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$517.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,298.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,283.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,017.75
|
| Rate for Payer: PHCS Commercial |
$1,416.00
|
| Rate for Payer: United Healthcare All Payer |
$1,298.00
|
|
|
CYST ASPIRATION U/S GUIDANCE(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402P0081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$278.08 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Ambetter Exchange |
$54.24
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$54.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$54.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.09
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$244.99
|
| Rate for Payer: Healthspan PPO |
$260.56
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$54.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.51
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$54.24
|
|
|
CYST ASPIRATION U/S GUIDANCE(T
|
Facility
|
IP
|
$1,275.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$981.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$994.50
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$1,058.25
|
| Rate for Payer: First Health Commercial |
$1,211.25
|
| Rate for Payer: Humana Commercial |
$1,083.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,045.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$940.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$382.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,122.00
|
| Rate for Payer: Ohio Health Group HMO |
$956.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,109.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$879.75
|
| Rate for Payer: PHCS Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare All Payer |
$1,122.00
|
|
|
CYST ASPIRATION U/S GUIDANCE(T
|
Facility
|
OP
|
$1,275.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$981.75
|
| Rate for Payer: Anthem Medicaid |
$438.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$994.50
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$1,058.25
|
| Rate for Payer: First Health Commercial |
$1,211.25
|
| Rate for Payer: Humana Commercial |
$1,083.75
|
| Rate for Payer: Humana KY Medicaid |
$438.47
|
| Rate for Payer: Kentucky WC Medicaid |
$442.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,045.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$940.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$382.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$447.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,122.00
|
| Rate for Payer: Ohio Health Group HMO |
$956.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,109.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$879.75
|
| Rate for Payer: PHCS Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare All Payer |
$1,122.00
|
|
|
CYSTATIN C
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 82610
|
| Hospital Charge Code |
30001875
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.52 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem Medicaid |
$18.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.52
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| 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 |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.89
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
CYSTATIN C
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 82610
|
| Hospital Charge Code |
30001875
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.04
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.89
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
CYSTECTOMY, PARTIAL; SIMPLE
|
Facility
|
IP
|
$2,350.00
|
|
|
Service Code
|
HCPCS 51550
|
| Hospital Charge Code |
76102062
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$705.00 |
| 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 |
$1,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,044.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,621.50
|
| 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 |
$1,543.96 |
| Rate for Payer: Aetna Commercial |
$1,543.96
|
| Rate for Payer: Ambetter Exchange |
$910.28
|
| Rate for Payer: Anthem Medicaid |
$736.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$910.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$910.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,092.34
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$910.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$910.28
|
| 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 |
$1,183.36
|
| Rate for Payer: UHCCP Medicaid |
$822.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$743.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$910.28
|
|
|
CYSTECTOMY, PARTIAL; SIMPLE
|
Facility
|
OP
|
$2,350.00
|
|
|
Service Code
|
HCPCS 51550
|
| Hospital Charge Code |
76102062
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$705.00 |
| 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 |
$1,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,044.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,621.50
|
| 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 |
$1,543.96 |
| Rate for Payer: Aetna Commercial |
$1,543.96
|
| Rate for Payer: Ambetter Exchange |
$910.28
|
| Rate for Payer: Anthem Medicaid |
$736.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$910.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$910.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,092.34
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$910.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$910.28
|
| 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 |
$1,183.36
|
| Rate for Payer: UHCCP Medicaid |
$822.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$743.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$910.28
|
|
|
CYSTO-CONRAY II 250ML
|
Facility
|
OP
|
$987.26
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
25003842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$296.18 |
| 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 |
$740.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$858.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$681.21
|
| Rate for Payer: PHCS Commercial |
$947.77
|
| Rate for Payer: United Healthcare All Payer |
$868.79
|
|
|
CYSTO-CONRAY II 250ML
|
Facility
|
IP
|
$987.26
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
25003842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$296.18 |
| 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 |
$740.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$858.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$681.21
|
| Rate for Payer: PHCS Commercial |
$947.77
|
| Rate for Payer: United Healthcare All Payer |
$868.79
|
|
|
CYSTO FRAGMENT URETERAL STONE
|
Professional
|
Both
|
$7,535.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
76102101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.98 |
| Max. Negotiated Rate |
$4,521.00 |
| Rate for Payer: Aetna Commercial |
$535.17
|
| Rate for Payer: Ambetter Exchange |
$299.98
|
| Rate for Payer: Anthem Medicaid |
$385.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$299.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$299.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$359.98
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$299.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$299.98
|
| 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 |
$389.97
|
| Rate for Payer: UHCCP Medicaid |
$2,637.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$389.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$299.98
|
|
|
CYSTO FRAGMENT URETERAL STONE
|
Facility
|
OP
|
$7,535.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
76102101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,591.29 |
| 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 |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,877.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,576.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,341.17
|
| 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 |
$4,697.16
|
| 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 |
$5,636.59
|
| 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 |
$6,028.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,555.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,199.15
|
| Rate for Payer: PHCS Commercial |
$7,233.60
|
| Rate for Payer: United Healthcare All Payer |
$6,630.80
|
|
|
CYSTO FRAGMENT URETERAL STONE
|
Facility
|
IP
|
$7,535.00
|
|
|
Service Code
|
HCPCS 52325
|
| Hospital Charge Code |
76102101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,260.50 |
| 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 |
$6,028.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,555.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,199.15
|
| Rate for Payer: PHCS Commercial |
$7,233.60
|
| Rate for Payer: United Healthcare All Payer |
$6,630.80
|
|
