|
CYSTOSTO CYSTO W DRAINAGE(T
|
Facility
|
OP
|
$5,826.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
761T2059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,593.85 |
| Rate for Payer: Aetna Commercial |
$4,486.74
|
| Rate for Payer: Anthem Medicaid |
$2,003.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,545.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$2,913.47
|
| Rate for Payer: Cash Price |
$2,913.47
|
| Rate for Payer: Cigna Commercial |
$4,836.35
|
| Rate for Payer: First Health Commercial |
$5,535.58
|
| Rate for Payer: Humana Commercial |
$4,952.89
|
| Rate for Payer: Humana KY Medicaid |
$2,003.88
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,024.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,778.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,300.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,044.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,127.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,370.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,661.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,069.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,020.58
|
| Rate for Payer: PHCS Commercial |
$5,593.85
|
| Rate for Payer: United Healthcare All Payer |
$5,127.70
|
|
|
CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE
|
Facility
|
OP
|
$2,649.89
|
|
|
Service Code
|
CPT 51040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$2,649.89 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
|
|
CYSTOTOMY,W/EVAC BLOOD CLOTS
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 53899
|
| Hospital Charge Code |
76102795
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
CYSTOTOMY,W/EVAC BLOOD CLOTS
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 53899
|
| Hospital Charge Code |
76102795
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
CYSTOTOMY,W/EVAC BLOOD CLOTS
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 53899
|
| Hospital Charge Code |
76102795
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
|
|
CYSTO/URETERO STRICTURE TX
|
Facility
|
OP
|
$5,314.46
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
76102105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,827.64 |
| Max. Negotiated Rate |
$5,101.88 |
| Rate for Payer: Aetna Commercial |
$4,092.13
|
| Rate for Payer: Anthem Medicaid |
$1,827.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,145.28
|
| 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 |
$2,657.23
|
| Rate for Payer: Cash Price |
$2,657.23
|
| Rate for Payer: Cigna Commercial |
$4,411.00
|
| Rate for Payer: First Health Commercial |
$5,048.74
|
| Rate for Payer: Humana Commercial |
$4,517.29
|
| Rate for Payer: Humana KY Medicaid |
$1,827.64
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,846.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,357.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,922.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,864.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,676.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,985.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,251.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,623.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,666.98
|
| Rate for Payer: PHCS Commercial |
$5,101.88
|
| Rate for Payer: United Healthcare All Payer |
$4,676.72
|
|
|
CYSTO/URETERO STRICTURE TX
|
Facility
|
IP
|
$5,314.46
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
76102105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,594.34 |
| Max. Negotiated Rate |
$5,101.88 |
| Rate for Payer: Aetna Commercial |
$4,092.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,145.28
|
| Rate for Payer: Cash Price |
$2,657.23
|
| Rate for Payer: Cigna Commercial |
$4,411.00
|
| Rate for Payer: First Health Commercial |
$5,048.74
|
| Rate for Payer: Humana Commercial |
$4,517.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,357.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,922.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,594.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,676.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,985.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,251.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,623.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,666.98
|
| Rate for Payer: PHCS Commercial |
$5,101.88
|
| Rate for Payer: United Healthcare All Payer |
$4,676.72
|
|
|
CYSTO/URETERO STRICTURE TX
|
Professional
|
Both
|
$5,314.46
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
76102105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$311.60 |
| Max. Negotiated Rate |
$3,188.68 |
| Rate for Payer: Aetna Commercial |
$637.77
|
| Rate for Payer: Ambetter Exchange |
$346.32
|
| Rate for Payer: Anthem Medicaid |
$311.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$346.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$346.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$415.58
|
| Rate for Payer: Cash Price |
$2,657.23
|
| Rate for Payer: Cash Price |
$2,657.23
|
| Rate for Payer: Cigna Commercial |
$616.01
|
| Rate for Payer: Healthspan PPO |
$509.95
|
| Rate for Payer: Humana Medicaid |
$311.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$521.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$346.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$346.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$317.83
|
| Rate for Payer: Molina Healthcare Passport |
$311.60
|
| Rate for Payer: Multiplan PHCS |
$3,188.68
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$450.22
|
| Rate for Payer: UHCCP Medicaid |
$1,860.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$314.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$346.32
|
|
|
CYSTO/URETERO STRICTURE TX(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
761P2105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$637.77 |
| Rate for Payer: Aetna Commercial |
$637.77
|
| Rate for Payer: Ambetter Exchange |
$346.32
|
| Rate for Payer: Anthem Medicaid |
$311.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$346.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$346.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$415.58
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$616.01
|
| Rate for Payer: Healthspan PPO |
$509.95
|
| Rate for Payer: Humana Medicaid |
$311.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$521.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$346.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$346.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$317.83
|
| Rate for Payer: Molina Healthcare Passport |
$311.60
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$450.22
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$314.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$346.32
|
|
|
CYSTO/URETERO STRICTURE TX(T
|
Facility
|
IP
|
$4,614.46
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
761T2105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,384.34 |
| Max. Negotiated Rate |
$4,429.88 |
| Rate for Payer: Aetna Commercial |
$3,553.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,599.28
|
| Rate for Payer: Cash Price |
$2,307.23
|
| Rate for Payer: Cigna Commercial |
$3,830.00
|
| Rate for Payer: First Health Commercial |
$4,383.74
|
| Rate for Payer: Humana Commercial |
$3,922.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,783.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,405.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,384.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,060.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,460.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,691.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,014.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,183.98
|
| Rate for Payer: PHCS Commercial |
$4,429.88
|
| Rate for Payer: United Healthcare All Payer |
$4,060.72
|
|
|
CYSTO/URETERO STRICTURE TX(T
|
Facility
|
OP
|
$4,614.46
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
761T2105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,586.91 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Aetna Commercial |
$3,553.13
|
| Rate for Payer: Anthem Medicaid |
$1,586.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,599.28
|
| 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 |
$2,307.23
|
| Rate for Payer: Cash Price |
$2,307.23
|
| Rate for Payer: Cigna Commercial |
$3,830.00
|
| Rate for Payer: First Health Commercial |
$4,383.74
|
| Rate for Payer: Humana Commercial |
$3,922.29
|
| Rate for Payer: Humana KY Medicaid |
$1,586.91
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,603.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,783.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,405.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,618.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,060.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,460.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,691.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,014.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,183.98
|
| Rate for Payer: PHCS Commercial |
$4,429.88
|
| Rate for Payer: United Healthcare All Payer |
$4,060.72
|
|
|
CYSTO/URETERO W/LITHOTRIPSY
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
76102111
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$739.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
CYSTO/URETERO W/LITHOTRIPSY
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
76102111
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$297.50 |
| Max. Negotiated Rate |
$682.79 |
| Rate for Payer: Ambetter Exchange |
$389.90
|
| Rate for Payer: Anthem Medicaid |
$334.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$389.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$389.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$467.88
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$682.79
|
| Rate for Payer: Healthspan PPO |
$535.50
|
| Rate for Payer: Humana Medicaid |
$334.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$563.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$389.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$389.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$340.99
|
| Rate for Payer: Molina Healthcare Passport |
$334.30
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$506.87
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$337.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$389.90
|
|
|
CYSTO/URETERO W/LITHOTRIPSY
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
76102111
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.31 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem Medicaid |
$292.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| 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 |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Humana KY Medicaid |
$292.31
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$295.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$739.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
CYSTO/URETERO W/LITHOTRIPSY(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
761P2111
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$297.50 |
| Max. Negotiated Rate |
$682.79 |
| Rate for Payer: Ambetter Exchange |
$389.90
|
| Rate for Payer: Anthem Medicaid |
$334.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$389.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$389.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$467.88
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$682.79
|
| Rate for Payer: Healthspan PPO |
$535.50
|
| Rate for Payer: Humana Medicaid |
$334.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$563.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$389.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$389.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$340.99
|
| Rate for Payer: Molina Healthcare Passport |
$334.30
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$506.87
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$337.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$389.90
|
|
|
CYSTOURETERO W/RENAL STRICT
|
Professional
|
Both
|
$1,088.00
|
|
|
Service Code
|
HCPCS 52346
|
| Hospital Charge Code |
76102877
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$373.63 |
| Max. Negotiated Rate |
$767.46 |
| Rate for Payer: Aetna Commercial |
$767.46
|
| Rate for Payer: Ambetter Exchange |
$418.03
|
| Rate for Payer: Anthem Medicaid |
$373.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$418.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$418.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.64
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$732.39
|
| Rate for Payer: Healthspan PPO |
$613.66
|
| Rate for Payer: Humana Medicaid |
$373.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$627.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$418.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$418.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$381.10
|
| Rate for Payer: Molina Healthcare Passport |
$373.63
|
| Rate for Payer: Multiplan PHCS |
$652.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$543.44
|
| Rate for Payer: UHCCP Medicaid |
$380.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$377.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$418.03
|
|
|
CYSTOURETERO W/RENAL STRICT
|
Facility
|
IP
|
$1,088.00
|
|
|
Service Code
|
HCPCS 52346
|
| Hospital Charge Code |
76102877
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$1,044.48 |
| Rate for Payer: Aetna Commercial |
$837.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$848.64
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$903.04
|
| Rate for Payer: First Health Commercial |
$1,033.60
|
| Rate for Payer: Humana Commercial |
$924.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$802.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$326.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$957.44
|
| Rate for Payer: Ohio Health Group HMO |
$816.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.72
|
| Rate for Payer: PHCS Commercial |
$1,044.48
|
| Rate for Payer: United Healthcare All Payer |
$957.44
|
|
|
CYSTOURETERO W/RENAL STRICT
|
Facility
|
OP
|
$1,088.00
|
|
|
Service Code
|
HCPCS 52346
|
| Hospital Charge Code |
76102877
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$374.16 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Aetna Commercial |
$837.76
|
| Rate for Payer: Anthem Medicaid |
$374.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$848.64
|
| 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 |
$544.00
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$903.04
|
| Rate for Payer: First Health Commercial |
$1,033.60
|
| Rate for Payer: Humana Commercial |
$924.80
|
| Rate for Payer: Humana KY Medicaid |
$374.16
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$377.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$802.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$381.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$957.44
|
| Rate for Payer: Ohio Health Group HMO |
$816.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.72
|
| Rate for Payer: PHCS Commercial |
$1,044.48
|
| Rate for Payer: United Healthcare All Payer |
$957.44
|
|
|
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH MANIPULATION, WITHOUT REMOVAL OF URETERAL CALCULUS
|
Facility
|
OP
|
$4,461.49
|
|
|
Service Code
|
CPT 52330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,186.78 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
|
|
CYSTOURETHROSCOPY (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$863.42
|
|
|
Service Code
|
CPT 52000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$863.42 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
|
|
CYSTOURETHROSCOPY SEP PX
|
Professional
|
Both
|
$4,455.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
76102081
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.84 |
| Max. Negotiated Rate |
$2,673.00 |
| Rate for Payer: Aetna Commercial |
$204.54
|
| Rate for Payer: Ambetter Exchange |
$75.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.84
|
| Rate for Payer: Anthem Medicaid |
$83.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$75.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$90.65
|
| Rate for Payer: Cash Price |
$2,227.50
|
| Rate for Payer: Cash Price |
$2,227.50
|
| Rate for Payer: Cigna Commercial |
$314.10
|
| Rate for Payer: Healthspan PPO |
$264.55
|
| Rate for Payer: Humana Medicaid |
$83.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$171.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$75.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.94
|
| Rate for Payer: Molina Healthcare Passport |
$83.27
|
| Rate for Payer: Multiplan PHCS |
$2,673.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$98.20
|
| Rate for Payer: UHCCP Medicaid |
$54.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$75.54
|
|
|
CYSTOURETHROSCOPY SEP PX
|
Facility
|
OP
|
$4,455.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
76102081
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$4,276.80 |
| Rate for Payer: Aetna Commercial |
$3,430.35
|
| Rate for Payer: Anthem Medicaid |
$1,532.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,474.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$2,227.50
|
| Rate for Payer: Cash Price |
$2,227.50
|
| Rate for Payer: Cigna Commercial |
$3,697.65
|
| Rate for Payer: First Health Commercial |
$4,232.25
|
| Rate for Payer: Humana Commercial |
$3,786.75
|
| Rate for Payer: Humana KY Medicaid |
$1,532.07
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1,547.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,653.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,287.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,562.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,920.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,341.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,564.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,875.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,073.95
|
| Rate for Payer: PHCS Commercial |
$4,276.80
|
| Rate for Payer: United Healthcare All Payer |
$3,920.40
|
|
|
CYSTOURETHROSCOPY SEP PX
|
Facility
|
IP
|
$4,455.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
76102081
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,336.50 |
| Max. Negotiated Rate |
$4,276.80 |
| Rate for Payer: Aetna Commercial |
$3,430.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,474.90
|
| Rate for Payer: Cash Price |
$2,227.50
|
| Rate for Payer: Cigna Commercial |
$3,697.65
|
| Rate for Payer: First Health Commercial |
$4,232.25
|
| Rate for Payer: Humana Commercial |
$3,786.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,653.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,287.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,336.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,920.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,341.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,564.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,875.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,073.95
|
| Rate for Payer: PHCS Commercial |
$4,276.80
|
| Rate for Payer: United Healthcare All Payer |
$3,920.40
|
|
|
CYSTOURETHROSCOPY SEP PX(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
761P2081
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.84 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$204.54
|
| Rate for Payer: Ambetter Exchange |
$75.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.84
|
| Rate for Payer: Anthem Medicaid |
$83.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$75.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$90.65
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$314.10
|
| Rate for Payer: Healthspan PPO |
$264.55
|
| Rate for Payer: Humana Medicaid |
$83.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$171.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$75.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.94
|
| Rate for Payer: Molina Healthcare Passport |
$83.27
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$98.20
|
| Rate for Payer: UHCCP Medicaid |
$54.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$75.54
|
|
|
CYSTOURETHROSCOPY SEP PX(T
|
Facility
|
OP
|
$3,855.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
761T2081
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$3,700.80 |
| Rate for Payer: Aetna Commercial |
$2,968.35
|
| Rate for Payer: Anthem Medicaid |
$1,325.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,006.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$1,927.50
|
| Rate for Payer: Cash Price |
$1,927.50
|
| Rate for Payer: Cigna Commercial |
$3,199.65
|
| Rate for Payer: First Health Commercial |
$3,662.25
|
| Rate for Payer: Humana Commercial |
$3,276.75
|
| Rate for Payer: Humana KY Medicaid |
$1,325.73
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,161.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,844.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,392.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,891.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,084.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,353.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,659.95
|
| Rate for Payer: PHCS Commercial |
$3,700.80
|
| Rate for Payer: United Healthcare All Payer |
$3,392.40
|
|
