|
CYSTOMETROGRAM W/VP
|
Facility
|
OP
|
$1,616.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
76102786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$555.74 |
| Max. Negotiated Rate |
$1,551.36 |
| Rate for Payer: Aetna Commercial |
$1,244.32
|
| Rate for Payer: Anthem Medicaid |
$555.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,260.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$808.00
|
| Rate for Payer: Cash Price |
$808.00
|
| Rate for Payer: Cigna Commercial |
$1,341.28
|
| Rate for Payer: First Health Commercial |
$1,535.20
|
| Rate for Payer: Humana Commercial |
$1,373.60
|
| Rate for Payer: Humana KY Medicaid |
$555.74
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$561.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,325.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,192.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$566.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,422.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,212.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,405.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,115.04
|
| Rate for Payer: PHCS Commercial |
$1,551.36
|
| Rate for Payer: United Healthcare All Payer |
$1,422.08
|
|
|
CYSTOMETROGRAM W/VP
|
Facility
|
IP
|
$1,616.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
76102786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$484.80 |
| Max. Negotiated Rate |
$1,551.36 |
| Rate for Payer: Aetna Commercial |
$1,244.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,260.48
|
| Rate for Payer: Cash Price |
$808.00
|
| Rate for Payer: Cigna Commercial |
$1,341.28
|
| Rate for Payer: First Health Commercial |
$1,535.20
|
| Rate for Payer: Humana Commercial |
$1,373.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,325.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,192.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$484.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,422.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,212.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,405.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,115.04
|
| Rate for Payer: PHCS Commercial |
$1,551.36
|
| Rate for Payer: United Healthcare All Payer |
$1,422.08
|
|
|
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: 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 |
$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: 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 |
$78.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$398.14
|
| Rate for Payer: UHCCP Medicaid |
$45.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$246.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$306.26
|
|
|
CYSTOMETROGRAM W/VP (T
|
Facility
|
OP
|
$1,486.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
761T2786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$511.04 |
| Max. Negotiated Rate |
$1,426.56 |
| Rate for Payer: Aetna Commercial |
$1,144.22
|
| Rate for Payer: Anthem Medicaid |
$511.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,159.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$1,233.38
|
| Rate for Payer: First Health Commercial |
$1,411.70
|
| Rate for Payer: Humana Commercial |
$1,263.10
|
| Rate for Payer: Humana KY Medicaid |
$511.04
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$516.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,218.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,096.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$521.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,307.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,114.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,292.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.34
|
| Rate for Payer: PHCS Commercial |
$1,426.56
|
| Rate for Payer: United Healthcare All Payer |
$1,307.68
|
|
|
CYSTOMETROGRAM W/VP (T
|
Facility
|
IP
|
$1,486.00
|
|
|
Service Code
|
HCPCS 51728
|
| Hospital Charge Code |
761T2786
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.80 |
| Max. Negotiated Rate |
$1,426.56 |
| Rate for Payer: Aetna Commercial |
$1,144.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,159.08
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$1,233.38
|
| Rate for Payer: First Health Commercial |
$1,411.70
|
| Rate for Payer: Humana Commercial |
$1,263.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,218.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,096.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,307.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,114.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,292.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.34
|
| Rate for Payer: PHCS Commercial |
$1,426.56
|
| Rate for Payer: United Healthcare All Payer |
$1,307.68
|
|
|
CYSTOMETROGRAM W/VP&UP
|
Facility
|
IP
|
$1,360.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
32000263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$1,305.60 |
| Rate for Payer: Aetna Commercial |
$1,047.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,060.80
|
| Rate for Payer: Cash Price |
$680.00
|
| Rate for Payer: Cigna Commercial |
$1,128.80
|
| Rate for Payer: First Health Commercial |
$1,292.00
|
| Rate for Payer: Humana Commercial |
$1,156.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,115.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,003.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$408.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,196.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,020.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,088.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,183.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$938.40
|
| Rate for Payer: PHCS Commercial |
$1,305.60
|
| Rate for Payer: United Healthcare All Payer |
$1,196.80
|
|
|
CYSTOMETROGRAM W/VP&UP
|
Facility
|
OP
|
$1,360.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
32000263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$467.70 |
| Max. Negotiated Rate |
$1,305.60 |
| Rate for Payer: Aetna Commercial |
$1,047.20
|
| Rate for Payer: Anthem Medicaid |
$467.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,060.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$680.00
|
| Rate for Payer: Cash Price |
$680.00
|
| Rate for Payer: Cigna Commercial |
$1,128.80
|
| Rate for Payer: First Health Commercial |
$1,292.00
|
| Rate for Payer: Humana Commercial |
$1,156.00
|
| Rate for Payer: Humana KY Medicaid |
$467.70
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$472.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,115.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,003.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$477.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,196.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,020.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,088.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,183.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$938.40
|
| Rate for Payer: PHCS Commercial |
$1,305.60
|
| Rate for Payer: United Healthcare All Payer |
$1,196.80
|
|
|
CYSTOMETROGRAM W/VP&UP
|
Professional
|
Both
|
$1,360.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
32000263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$171.33 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$476.84
|
| Rate for Payer: Ambetter Exchange |
$325.52
|
| Rate for Payer: Anthem Medicaid |
$267.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$325.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$325.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$390.62
|
| Rate for Payer: Cash Price |
$680.00
|
| Rate for Payer: Cash Price |
$680.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$325.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$272.40
|
| Rate for Payer: Molina Healthcare Passport |
$267.06
|
| Rate for Payer: Multiplan PHCS |
$816.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$423.18
|
| Rate for Payer: UHCCP Medicaid |
$476.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$269.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$325.52
|
|
|
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: Ambetter Exchange |
$325.52
|
| Rate for Payer: Anthem Medicaid |
$267.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$325.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$325.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$390.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$325.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.52
|
| 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 |
$423.18
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$269.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$325.52
|
|
|
CYSTOMETROGRAM W/VP&UP(T
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
320T0263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$310.50 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna Commercial |
$796.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$807.30
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$859.05
|
| Rate for Payer: First Health Commercial |
$983.25
|
| Rate for Payer: Humana Commercial |
$879.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$310.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$910.80
|
| Rate for Payer: Ohio Health Group HMO |
$776.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$828.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$900.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$714.15
|
| Rate for Payer: PHCS Commercial |
$993.60
|
| Rate for Payer: United Healthcare All Payer |
$910.80
|
|
|
CYSTOMETROGRAM W/VP&UP(T
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 51729
|
| Hospital Charge Code |
320T0263
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$355.94 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna Commercial |
$796.95
|
| Rate for Payer: Anthem Medicaid |
$355.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$807.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$859.05
|
| Rate for Payer: First Health Commercial |
$983.25
|
| Rate for Payer: Humana Commercial |
$879.75
|
| Rate for Payer: Humana KY Medicaid |
$355.94
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$359.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$363.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$910.80
|
| Rate for Payer: Ohio Health Group HMO |
$776.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$828.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$900.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$714.15
|
| Rate for Payer: PHCS Commercial |
$993.60
|
| Rate for Payer: United Healthcare All Payer |
$910.80
|
|
|
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 |
$4,251.60 |
| Rate for Payer: Aetna Commercial |
$652.33
|
| Rate for Payer: Ambetter Exchange |
$391.41
|
| Rate for Payer: Anthem Medicaid |
$310.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.69
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$391.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.41
|
| 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 |
$508.83
|
| Rate for Payer: UHCCP Medicaid |
$2,480.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$313.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.41
|
|
|
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 |
$2,436.88 |
| Max. Negotiated Rate |
$6,802.56 |
| Rate for Payer: Aetna Commercial |
$5,456.22
|
| Rate for Payer: Anthem Medicaid |
$2,436.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,527.08
|
| 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 |
$3,543.00
|
| 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 |
$4,697.16
|
| 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 |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,485.77
|
| 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 |
$5,668.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,164.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,889.34
|
| 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 |
$2,125.80 |
| 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 |
$5,668.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,164.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,889.34
|
| Rate for Payer: PHCS Commercial |
$6,802.56
|
| Rate for Payer: United Healthcare All Payer |
$6,235.68
|
|
|
CYSTO/PYELO BX/FULG PEL LSN(P
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
761P2109
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$310.28 |
| Max. Negotiated Rate |
$652.33 |
| Rate for Payer: Aetna Commercial |
$652.33
|
| Rate for Payer: Ambetter Exchange |
$391.41
|
| Rate for Payer: Anthem Medicaid |
$310.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.69
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$391.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$316.49
|
| Rate for Payer: Molina Healthcare Passport |
$310.28
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$508.83
|
| Rate for Payer: UHCCP Medicaid |
$358.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$313.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.41
|
|
|
CYSTO/PYELO BX/FULG PEL LSN(T
|
Facility
|
OP
|
$6,061.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
761T2109
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,084.38 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Aetna Commercial |
$4,666.97
|
| Rate for Payer: Anthem Medicaid |
$2,084.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,727.58
|
| 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 |
$3,030.50
|
| Rate for Payer: Cash Price |
$3,030.50
|
| Rate for Payer: Cigna Commercial |
$5,030.63
|
| Rate for Payer: First Health Commercial |
$5,757.95
|
| Rate for Payer: Humana Commercial |
$5,151.85
|
| Rate for Payer: Humana KY Medicaid |
$2,084.38
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,105.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,970.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,473.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,126.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,333.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,545.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,848.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,273.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,182.09
|
| Rate for Payer: PHCS Commercial |
$5,818.56
|
| Rate for Payer: United Healthcare All Payer |
$5,333.68
|
|
|
CYSTO/PYELO BX/FULG PEL LSN(T
|
Facility
|
IP
|
$6,061.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
761T2109
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,818.30 |
| Max. Negotiated Rate |
$5,818.56 |
| Rate for Payer: Aetna Commercial |
$4,666.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,727.58
|
| Rate for Payer: Cash Price |
$3,030.50
|
| Rate for Payer: Cigna Commercial |
$5,030.63
|
| Rate for Payer: First Health Commercial |
$5,757.95
|
| Rate for Payer: Humana Commercial |
$5,151.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,970.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,473.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,818.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,333.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,545.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,848.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,273.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,182.09
|
| Rate for Payer: PHCS Commercial |
$5,818.56
|
| Rate for Payer: United Healthcare All Payer |
$5,333.68
|
|
|
CYSTO/PYELOSCOPY RESCJ PEL TUM
|
Professional
|
Both
|
$7,061.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
76102110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.94 |
| Max. Negotiated Rate |
$4,236.60 |
| Rate for Payer: Aetna Commercial |
$778.25
|
| Rate for Payer: Ambetter Exchange |
$438.67
|
| Rate for Payer: Anthem Medicaid |
$364.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$438.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$438.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$526.40
|
| Rate for Payer: Cash Price |
$3,530.50
|
| Rate for Payer: Cash Price |
$3,530.50
|
| Rate for Payer: Cigna Commercial |
$692.99
|
| Rate for Payer: Healthspan PPO |
$622.28
|
| Rate for Payer: Humana Medicaid |
$364.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$640.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$438.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$438.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$372.24
|
| Rate for Payer: Molina Healthcare Passport |
$364.94
|
| Rate for Payer: Multiplan PHCS |
$4,236.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$570.27
|
| Rate for Payer: UHCCP Medicaid |
$2,471.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$368.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$438.67
|
|
|
CYSTO/PYELOSCOPY RESCJ PEL TUM
|
Facility
|
OP
|
$7,061.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
76102110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,428.28 |
| Max. Negotiated Rate |
$6,778.56 |
| Rate for Payer: Aetna Commercial |
$5,436.97
|
| Rate for Payer: Anthem Medicaid |
$2,428.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,507.58
|
| 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 |
$3,530.50
|
| Rate for Payer: Cash Price |
$3,530.50
|
| Rate for Payer: Cigna Commercial |
$5,860.63
|
| Rate for Payer: First Health Commercial |
$6,707.95
|
| Rate for Payer: Humana Commercial |
$6,001.85
|
| Rate for Payer: Humana KY Medicaid |
$2,428.28
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,452.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,790.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,211.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,477.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,213.68
|
| Rate for Payer: Ohio Health Group HMO |
$5,295.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,648.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,143.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,872.09
|
| Rate for Payer: PHCS Commercial |
$6,778.56
|
| Rate for Payer: United Healthcare All Payer |
$6,213.68
|
|
|
CYSTO/PYELOSCOPY RESCJ PEL TUM
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
761P2110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$778.25 |
| Rate for Payer: Aetna Commercial |
$778.25
|
| Rate for Payer: Ambetter Exchange |
$438.67
|
| Rate for Payer: Anthem Medicaid |
$364.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$438.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$438.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$526.40
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$692.99
|
| Rate for Payer: Healthspan PPO |
$622.28
|
| Rate for Payer: Humana Medicaid |
$364.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$640.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$438.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$438.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$372.24
|
| Rate for Payer: Molina Healthcare Passport |
$364.94
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$570.27
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$368.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$438.67
|
|
|
CYSTO/PYELOSCOPY RESCJ PEL TUM
|
Facility
|
IP
|
$6,061.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
761T2110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,818.30 |
| Max. Negotiated Rate |
$5,818.56 |
| Rate for Payer: Aetna Commercial |
$4,666.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,727.58
|
| Rate for Payer: Cash Price |
$3,030.50
|
| Rate for Payer: Cigna Commercial |
$5,030.63
|
| Rate for Payer: First Health Commercial |
$5,757.95
|
| Rate for Payer: Humana Commercial |
$5,151.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,970.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,473.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,818.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,333.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,545.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,848.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,273.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,182.09
|
| Rate for Payer: PHCS Commercial |
$5,818.56
|
| Rate for Payer: United Healthcare All Payer |
$5,333.68
|
|
|
CYSTO/PYELOSCOPY RESCJ PEL TUM
|
Facility
|
OP
|
$6,061.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
761T2110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,084.38 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Aetna Commercial |
$4,666.97
|
| Rate for Payer: Anthem Medicaid |
$2,084.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,727.58
|
| 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 |
$3,030.50
|
| Rate for Payer: Cash Price |
$3,030.50
|
| Rate for Payer: Cigna Commercial |
$5,030.63
|
| Rate for Payer: First Health Commercial |
$5,757.95
|
| Rate for Payer: Humana Commercial |
$5,151.85
|
| Rate for Payer: Humana KY Medicaid |
$2,084.38
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,105.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,970.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,473.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,126.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,333.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,545.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,848.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,273.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,182.09
|
| Rate for Payer: PHCS Commercial |
$5,818.56
|
| Rate for Payer: United Healthcare All Payer |
$5,333.68
|
|
|
CYSTO/PYELOSCOPY RESCJ PEL TUM
|
Facility
|
IP
|
$7,061.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
76102110
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,118.30 |
| Max. Negotiated Rate |
$6,778.56 |
| Rate for Payer: Aetna Commercial |
$5,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,507.58
|
| Rate for Payer: Cash Price |
$3,530.50
|
| Rate for Payer: Cigna Commercial |
$5,860.63
|
| Rate for Payer: First Health Commercial |
$6,707.95
|
| Rate for Payer: Humana Commercial |
$6,001.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,790.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,211.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,118.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,213.68
|
| Rate for Payer: Ohio Health Group HMO |
$5,295.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,648.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,143.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,872.09
|
| Rate for Payer: PHCS Commercial |
$6,778.56
|
| Rate for Payer: United Healthcare All Payer |
$6,213.68
|
|
|
CYSTO RX BALO CATH URTL STRX
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 52284
|
| Hospital Charge Code |
76102957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$124.42 |
| Max. Negotiated Rate |
$2,142.66 |
| Rate for Payer: Ambetter Exchange |
$155.15
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$124.42
|
| Rate for Payer: Anthem Medicaid |
$2,100.65
|
| Rate for Payer: Buckeye Individual/Medicaid |
$155.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.18
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Humana Medicaid |
$2,100.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$155.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$2,142.66
|
| Rate for Payer: Molina Healthcare Passport |
$2,100.65
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$201.69
|
| Rate for Payer: UHCCP Medicaid |
$130.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,121.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$155.15
|
|
|
CYSTO RX BALO CATH URTL STRX
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 52284
|
| Hospital Charge Code |
76102957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
