|
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 |
$299.98 |
| Max. Negotiated Rate |
$780.00 |
| 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 |
$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: 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 |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$389.97
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$389.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$299.98
|
|
|
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 |
$2,144.22 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Aetna Commercial |
$4,800.95
|
| Rate for Payer: Anthem Medicaid |
$2,144.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,863.30
|
| 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 |
$3,117.50
|
| 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 |
$4,697.16
|
| 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 |
$5,636.59
|
| 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 |
$4,988.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,424.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,302.15
|
| Rate for Payer: PHCS Commercial |
$5,985.60
|
| Rate for Payer: United Healthcare All Payer |
$5,486.80
|
|
|
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 |
$1,870.50 |
| 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 |
$4,988.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,424.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,302.15
|
| 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 |
$356.21 |
| 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 |
$949.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,033.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$819.29
|
| 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 |
$356.21 |
| 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 |
$949.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,033.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$819.29
|
| Rate for Payer: PHCS Commercial |
$1,139.88
|
| Rate for Payer: United Healthcare All Payer |
$1,044.89
|
|
|
CYSTOGRAM STATIC 3V
|
Professional
|
Both
|
$639.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
32000146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$383.40 |
| Rate for Payer: Aetna Commercial |
$117.84
|
| Rate for Payer: Ambetter Exchange |
$37.58
|
| Rate for Payer: Anthem Medicaid |
$42.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$45.10
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cash Price |
$319.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$37.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.27
|
| Rate for Payer: Molina Healthcare Passport |
$42.42
|
| Rate for Payer: Multiplan PHCS |
$383.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$48.85
|
| Rate for Payer: UHCCP Medicaid |
$223.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.58
|
|
|
CYSTOGRAM STATIC 3V
|
Facility
|
IP
|
$639.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
32000146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$191.70 |
| Max. Negotiated Rate |
$613.44 |
| Rate for Payer: Aetna Commercial |
$492.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$498.42
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cigna Commercial |
$530.37
|
| Rate for Payer: First Health Commercial |
$607.05
|
| Rate for Payer: Humana Commercial |
$543.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$523.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$471.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$191.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$562.32
|
| Rate for Payer: Ohio Health Group HMO |
$479.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$511.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$555.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$440.91
|
| Rate for Payer: PHCS Commercial |
$613.44
|
| Rate for Payer: United Healthcare All Payer |
$562.32
|
|
|
CYSTOGRAM STATIC 3V
|
Facility
|
OP
|
$639.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
32000146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.75 |
| Max. Negotiated Rate |
$613.44 |
| Rate for Payer: Aetna Commercial |
$492.03
|
| Rate for Payer: Anthem Medicaid |
$219.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$498.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cigna Commercial |
$530.37
|
| Rate for Payer: First Health Commercial |
$607.05
|
| Rate for Payer: Humana Commercial |
$543.15
|
| Rate for Payer: Humana KY Medicaid |
$219.75
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$221.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$523.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$471.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$562.32
|
| Rate for Payer: Ohio Health Group HMO |
$479.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$511.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$555.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$440.91
|
| Rate for Payer: PHCS Commercial |
$613.44
|
| Rate for Payer: United Healthcare All Payer |
$562.32
|
|
|
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: Ambetter Exchange |
$37.58
|
| Rate for Payer: Anthem Medicaid |
$42.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$45.10
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$37.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.58
|
| 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 |
$48.85
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.58
|
|
|
CYSTOGRAM STATIC 3V(T
|
Facility
|
OP
|
$564.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
320T0146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$193.96 |
| Max. Negotiated Rate |
$541.44 |
| Rate for Payer: Aetna Commercial |
$434.28
|
| Rate for Payer: Anthem Medicaid |
$193.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$468.12
|
| Rate for Payer: First Health Commercial |
$535.80
|
| Rate for Payer: Humana Commercial |
$479.40
|
| Rate for Payer: Humana KY Medicaid |
$193.96
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$195.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$462.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$197.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$496.32
|
| Rate for Payer: Ohio Health Group HMO |
$423.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$451.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.16
|
| Rate for Payer: PHCS Commercial |
$541.44
|
| Rate for Payer: United Healthcare All Payer |
$496.32
|
|
|
CYSTOGRAM STATIC 3V(T
|
Facility
|
IP
|
$564.00
|
|
|
Service Code
|
HCPCS 74430
|
| Hospital Charge Code |
320T0146
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$541.44 |
| Rate for Payer: Aetna Commercial |
$434.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.92
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$468.12
|
| Rate for Payer: First Health Commercial |
$535.80
|
| Rate for Payer: Humana Commercial |
$479.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$462.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$496.32
|
| Rate for Payer: Ohio Health Group HMO |
$423.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$451.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.16
|
| Rate for Payer: PHCS Commercial |
$541.44
|
| Rate for Payer: United Healthcare All Payer |
$496.32
|
|
|
CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION
|
Facility
|
OP
|
$6,576.02
|
|
|
Service Code
|
CPT 51050
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,697.16 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,576.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,341.17
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
|
|
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 |
$3,797.30 |
| Rate for Payer: Aetna Commercial |
$440.19
|
| Rate for Payer: Ambetter Exchange |
$247.03
|
| 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 Individual/Medicaid |
$247.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$247.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$296.44
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$247.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.03
|
| 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 |
$321.14
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$251.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$247.03
|
|
|
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 |
$2,176.49 |
| 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 |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,936.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| 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 |
$3,186.78
|
| 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 |
$3,824.14
|
| 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 |
$5,063.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,506.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,366.90
|
| 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
|
Facility
|
IP
|
$6,328.84
|
|
|
Service Code
|
HCPCS 52330
|
| Hospital Charge Code |
76102102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,898.65 |
| 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 |
$5,063.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,506.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,366.90
|
| 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 |
$1,185.00 |
| Rate for Payer: Aetna Commercial |
$440.19
|
| Rate for Payer: Ambetter Exchange |
$247.03
|
| 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 Individual/Medicaid |
$247.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$247.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$296.44
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$247.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.03
|
| 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 |
$321.14
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$251.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$247.03
|
|
|
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 |
$1,497.29 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Aetna Commercial |
$3,352.46
|
| Rate for Payer: Anthem Medicaid |
$1,497.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,396.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| 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 |
$3,186.78
|
| 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 |
$3,824.14
|
| 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 |
$3,483.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,787.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,004.15
|
| 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 |
$1,306.15 |
| 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 |
$3,483.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,787.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,004.15
|
| Rate for Payer: PHCS Commercial |
$4,179.69
|
| Rate for Payer: United Healthcare All Payer |
$3,831.38
|
|
|
CYSTOMETROGRAM W/UP
|
Facility
|
IP
|
$1,493.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
76102785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$447.90 |
| Max. Negotiated Rate |
$1,433.28 |
| Rate for Payer: Aetna Commercial |
$1,149.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,164.54
|
| Rate for Payer: Cash Price |
$746.50
|
| Rate for Payer: Cigna Commercial |
$1,239.19
|
| Rate for Payer: First Health Commercial |
$1,418.35
|
| Rate for Payer: Humana Commercial |
$1,269.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,224.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,101.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$447.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,313.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,119.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,194.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,298.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,030.17
|
| Rate for Payer: PHCS Commercial |
$1,433.28
|
| Rate for Payer: United Healthcare All Payer |
$1,313.84
|
|
|
CYSTOMETROGRAM W/UP
|
Professional
|
Both
|
$1,493.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
76102785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.42 |
| Max. Negotiated Rate |
$895.80 |
| Rate for Payer: Aetna Commercial |
$443.54
|
| Rate for Payer: Ambetter Exchange |
$307.89
|
| Rate for Payer: Anthem Medicaid |
$245.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$307.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$307.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$369.47
|
| Rate for Payer: Cash Price |
$746.50
|
| Rate for Payer: Cash Price |
$746.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$307.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$250.18
|
| Rate for Payer: Molina Healthcare Passport |
$245.27
|
| Rate for Payer: Multiplan PHCS |
$895.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$400.26
|
| Rate for Payer: UHCCP Medicaid |
$522.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$247.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$307.89
|
|
|
CYSTOMETROGRAM W/UP
|
Facility
|
OP
|
$1,493.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
76102785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$513.44 |
| Max. Negotiated Rate |
$1,433.28 |
| Rate for Payer: Aetna Commercial |
$1,149.61
|
| Rate for Payer: Anthem Medicaid |
$513.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,164.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$746.50
|
| Rate for Payer: Cash Price |
$746.50
|
| Rate for Payer: Cigna Commercial |
$1,239.19
|
| Rate for Payer: First Health Commercial |
$1,418.35
|
| Rate for Payer: Humana Commercial |
$1,269.05
|
| Rate for Payer: Humana KY Medicaid |
$513.44
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$518.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,224.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,101.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$523.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,313.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,119.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,194.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,298.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,030.17
|
| Rate for Payer: PHCS Commercial |
$1,433.28
|
| Rate for Payer: United Healthcare All Payer |
$1,313.84
|
|
|
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: Ambetter Exchange |
$307.89
|
| Rate for Payer: Anthem Medicaid |
$245.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$307.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$307.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$369.47
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$307.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.89
|
| 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 |
$400.26
|
| Rate for Payer: UHCCP Medicaid |
$45.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$247.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$307.89
|
|
|
CYSTOMETROGRAM W/UP (T
|
Facility
|
OP
|
$1,363.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
761T2785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.74 |
| Max. Negotiated Rate |
$1,308.48 |
| Rate for Payer: Aetna Commercial |
$1,049.51
|
| Rate for Payer: Anthem Medicaid |
$468.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,063.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$681.50
|
| Rate for Payer: Cash Price |
$681.50
|
| Rate for Payer: Cigna Commercial |
$1,131.29
|
| Rate for Payer: First Health Commercial |
$1,294.85
|
| Rate for Payer: Humana Commercial |
$1,158.55
|
| Rate for Payer: Humana KY Medicaid |
$468.74
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$473.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,117.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,005.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$478.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,199.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,090.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,185.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$940.47
|
| Rate for Payer: PHCS Commercial |
$1,308.48
|
| Rate for Payer: United Healthcare All Payer |
$1,199.44
|
|
|
CYSTOMETROGRAM W/UP (T
|
Facility
|
IP
|
$1,363.00
|
|
|
Service Code
|
HCPCS 51727
|
| Hospital Charge Code |
761T2785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$408.90 |
| Max. Negotiated Rate |
$1,308.48 |
| Rate for Payer: Aetna Commercial |
$1,049.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,063.14
|
| Rate for Payer: Cash Price |
$681.50
|
| Rate for Payer: Cigna Commercial |
$1,131.29
|
| Rate for Payer: First Health Commercial |
$1,294.85
|
| Rate for Payer: Humana Commercial |
$1,158.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,117.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,005.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$408.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,199.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,090.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,185.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$940.47
|
| Rate for Payer: PHCS Commercial |
$1,308.48
|
| Rate for Payer: United Healthcare All Payer |
$1,199.44
|
|
|
CYSTOMETROGRAM W/VP
|
Professional
|
Both
|
$1,616.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
76102786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.92 |
| Max. Negotiated Rate |
$969.60 |
| Rate for Payer: Aetna Commercial |
$442.64
|
| Rate for Payer: Ambetter Exchange |
$306.26
|
| Rate for Payer: Anthem Medicaid |
$244.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$306.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$306.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$367.51
|
| Rate for Payer: Cash Price |
$808.00
|
| Rate for Payer: Cash Price |
$808.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$306.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$306.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$249.26
|
| Rate for Payer: Molina Healthcare Passport |
$244.37
|
| Rate for Payer: Multiplan PHCS |
$969.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$398.14
|
| Rate for Payer: UHCCP Medicaid |
$565.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$246.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$306.26
|
|
