|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)
|
Facility
|
OP
|
$4,461.49
|
|
|
Service Code
|
CPT 52352
|
|
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 WITH URETEROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$6,576.02
|
|
|
Service Code
|
CPT 52346
|
|
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
|
|
|
CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$4,461.49
|
|
|
Service Code
|
CPT 52344
|
|
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
|
|
|
CYSTOURETHRO W/ADDL IMPLANT
|
Professional
|
Both
|
$2,445.00
|
|
|
Service Code
|
HCPCS 52442
|
| Hospital Charge Code |
76102791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.92 |
| Max. Negotiated Rate |
$1,467.00 |
| Rate for Payer: Ambetter Exchange |
$47.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.53
|
| Rate for Payer: Anthem Medicaid |
$694.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$47.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.50
|
| Rate for Payer: Cash Price |
$1,222.50
|
| Rate for Payer: Cash Price |
$1,222.50
|
| Rate for Payer: Cigna Commercial |
$101.11
|
| Rate for Payer: Humana Medicaid |
$694.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$82.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$47.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$708.67
|
| Rate for Payer: Molina Healthcare Passport |
$694.77
|
| Rate for Payer: Multiplan PHCS |
$1,467.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$62.30
|
| Rate for Payer: UHCCP Medicaid |
$53.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$701.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.92
|
|
|
CYSTOURETHRO W/ADDL IMPLANT
|
Facility
|
IP
|
$2,445.00
|
|
|
Service Code
|
HCPCS 52442
|
| Hospital Charge Code |
76102791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$733.50 |
| Max. Negotiated Rate |
$2,347.20 |
| Rate for Payer: Aetna Commercial |
$1,882.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,907.10
|
| Rate for Payer: Cash Price |
$1,222.50
|
| Rate for Payer: Cigna Commercial |
$2,029.35
|
| Rate for Payer: First Health Commercial |
$2,322.75
|
| Rate for Payer: Humana Commercial |
$2,078.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,004.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,804.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$733.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,151.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,833.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,956.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,127.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.05
|
| Rate for Payer: PHCS Commercial |
$2,347.20
|
| Rate for Payer: United Healthcare All Payer |
$2,151.60
|
|
|
CYSTOURETHRO W/ADDL IMPLANT
|
Facility
|
OP
|
$2,445.00
|
|
|
Service Code
|
HCPCS 52442
|
| Hospital Charge Code |
76102791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$733.50 |
| Max. Negotiated Rate |
$2,347.20 |
| Rate for Payer: Aetna Commercial |
$1,882.65
|
| Rate for Payer: Anthem Medicaid |
$840.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,907.10
|
| Rate for Payer: Cash Price |
$1,222.50
|
| Rate for Payer: Cigna Commercial |
$2,029.35
|
| Rate for Payer: First Health Commercial |
$2,322.75
|
| Rate for Payer: Humana Commercial |
$2,078.25
|
| Rate for Payer: Humana KY Medicaid |
$840.84
|
| Rate for Payer: Kentucky WC Medicaid |
$849.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,004.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,804.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$733.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$857.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,151.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,833.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,956.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,127.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.05
|
| Rate for Payer: PHCS Commercial |
$2,347.20
|
| Rate for Payer: United Healthcare All Payer |
$2,151.60
|
|
|
CYSTOURETHRO W/ADDL IMPLANT (P
|
Professional
|
Both
|
$880.00
|
|
|
Service Code
|
HCPCS 52442
|
| Hospital Charge Code |
761P2791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.92 |
| Max. Negotiated Rate |
$708.67 |
| Rate for Payer: Ambetter Exchange |
$47.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.53
|
| Rate for Payer: Anthem Medicaid |
$694.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$47.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.50
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cigna Commercial |
$101.11
|
| Rate for Payer: Humana Medicaid |
$694.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$82.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$47.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$708.67
|
| Rate for Payer: Molina Healthcare Passport |
$694.77
|
| Rate for Payer: Multiplan PHCS |
$528.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$62.30
|
| Rate for Payer: UHCCP Medicaid |
$53.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$701.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.92
|
|
|
CYSTOURETHRO W/ADDL IMPLANT (T
|
Facility
|
OP
|
$1,565.00
|
|
|
Service Code
|
HCPCS 52442
|
| Hospital Charge Code |
761T2791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.50 |
| Max. Negotiated Rate |
$1,502.40 |
| Rate for Payer: Aetna Commercial |
$1,205.05
|
| Rate for Payer: Anthem Medicaid |
$538.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,220.70
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,298.95
|
| Rate for Payer: First Health Commercial |
$1,486.75
|
| Rate for Payer: Humana Commercial |
$1,330.25
|
| Rate for Payer: Humana KY Medicaid |
$538.20
|
| Rate for Payer: Kentucky WC Medicaid |
$543.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,283.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$549.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,377.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,361.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,079.85
|
| Rate for Payer: PHCS Commercial |
$1,502.40
|
| Rate for Payer: United Healthcare All Payer |
$1,377.20
|
|
|
CYSTOURETHRO W/ADDL IMPLANT (T
|
Facility
|
IP
|
$1,565.00
|
|
|
Service Code
|
HCPCS 52442
|
| Hospital Charge Code |
761T2791
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.50 |
| Max. Negotiated Rate |
$1,502.40 |
| Rate for Payer: Aetna Commercial |
$1,205.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,220.70
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,298.95
|
| Rate for Payer: First Health Commercial |
$1,486.75
|
| Rate for Payer: Humana Commercial |
$1,330.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,283.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,377.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,361.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,079.85
|
| Rate for Payer: PHCS Commercial |
$1,502.40
|
| Rate for Payer: United Healthcare All Payer |
$1,377.20
|
|
|
CYSTOURETHRO W/IMPLANT
|
Facility
|
IP
|
$4,410.00
|
|
|
Service Code
|
HCPCS 52441
|
| Hospital Charge Code |
76102790
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,323.00 |
| Max. Negotiated Rate |
$4,233.60 |
| Rate for Payer: Aetna Commercial |
$3,395.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,439.80
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Cigna Commercial |
$3,660.30
|
| Rate for Payer: First Health Commercial |
$4,189.50
|
| Rate for Payer: Humana Commercial |
$3,748.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,616.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,254.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,323.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,880.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,307.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,528.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,836.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,042.90
|
| Rate for Payer: PHCS Commercial |
$4,233.60
|
| Rate for Payer: United Healthcare All Payer |
$3,880.80
|
|
|
CYSTOURETHRO W/IMPLANT
|
Facility
|
OP
|
$4,410.00
|
|
|
Service Code
|
HCPCS 52441
|
| Hospital Charge Code |
76102790
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,323.00 |
| Max. Negotiated Rate |
$4,233.60 |
| Rate for Payer: Aetna Commercial |
$3,395.70
|
| Rate for Payer: Anthem Medicaid |
$1,516.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,439.80
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Cigna Commercial |
$3,660.30
|
| Rate for Payer: First Health Commercial |
$4,189.50
|
| Rate for Payer: Humana Commercial |
$3,748.50
|
| Rate for Payer: Humana KY Medicaid |
$1,516.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,532.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,616.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,254.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,323.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,547.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,880.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,307.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,528.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,836.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,042.90
|
| Rate for Payer: PHCS Commercial |
$4,233.60
|
| Rate for Payer: United Healthcare All Payer |
$3,880.80
|
|
|
CYSTOURETHRO W/IMPLANT
|
Professional
|
Both
|
$4,410.00
|
|
|
Service Code
|
HCPCS 52441
|
| Hospital Charge Code |
76102790
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$189.33 |
| Max. Negotiated Rate |
$2,646.00 |
| Rate for Payer: Ambetter Exchange |
$197.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$189.33
|
| Rate for Payer: Anthem Medicaid |
$918.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$197.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$197.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$236.84
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Cigna Commercial |
$377.94
|
| Rate for Payer: Humana Medicaid |
$918.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$308.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$197.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$937.22
|
| Rate for Payer: Molina Healthcare Passport |
$918.84
|
| Rate for Payer: Multiplan PHCS |
$2,646.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$256.58
|
| Rate for Payer: UHCCP Medicaid |
$198.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$928.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$197.37
|
|
|
CYSTOURETHRO W/IMPLANT (P
|
Professional
|
Both
|
$1,280.00
|
|
|
Service Code
|
HCPCS 52441
|
| Hospital Charge Code |
761P2790
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$189.33 |
| Max. Negotiated Rate |
$937.22 |
| Rate for Payer: Ambetter Exchange |
$197.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$189.33
|
| Rate for Payer: Anthem Medicaid |
$918.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$197.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$197.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$236.84
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cigna Commercial |
$377.94
|
| Rate for Payer: Humana Medicaid |
$918.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$308.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$197.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$937.22
|
| Rate for Payer: Molina Healthcare Passport |
$918.84
|
| Rate for Payer: Multiplan PHCS |
$768.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$256.58
|
| Rate for Payer: UHCCP Medicaid |
$198.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$928.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$197.37
|
|
|
CYSTOURETHRO W/IMPLANT (T
|
Facility
|
OP
|
$3,130.00
|
|
|
Service Code
|
HCPCS 52441
|
| Hospital Charge Code |
761T2790
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$939.00 |
| Max. Negotiated Rate |
$3,004.80 |
| Rate for Payer: Aetna Commercial |
$2,410.10
|
| Rate for Payer: Anthem Medicaid |
$1,076.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,441.40
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,597.90
|
| Rate for Payer: First Health Commercial |
$2,973.50
|
| Rate for Payer: Humana Commercial |
$2,660.50
|
| Rate for Payer: Humana KY Medicaid |
$1,076.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,087.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,566.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,309.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$939.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,098.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,754.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,347.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,723.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,159.70
|
| Rate for Payer: PHCS Commercial |
$3,004.80
|
| Rate for Payer: United Healthcare All Payer |
$2,754.40
|
|
|
CYSTOURETHRO W/IMPLANT (T
|
Facility
|
IP
|
$3,130.00
|
|
|
Service Code
|
HCPCS 52441
|
| Hospital Charge Code |
761T2790
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$939.00 |
| Max. Negotiated Rate |
$3,004.80 |
| Rate for Payer: Aetna Commercial |
$2,410.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,441.40
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,597.90
|
| Rate for Payer: First Health Commercial |
$2,973.50
|
| Rate for Payer: Humana Commercial |
$2,660.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,566.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,309.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$939.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,754.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,347.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,723.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,159.70
|
| Rate for Payer: PHCS Commercial |
$3,004.80
|
| Rate for Payer: United Healthcare All Payer |
$2,754.40
|
|
|
CYSTO W/COMP RMV STONE/STENT
|
Professional
|
Both
|
$7,113.00
|
|
|
Service Code
|
HCPCS 52315
|
| Hospital Charge Code |
76102097
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.42 |
| Max. Negotiated Rate |
$4,267.80 |
| Rate for Payer: Aetna Commercial |
$457.67
|
| Rate for Payer: Ambetter Exchange |
$257.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$157.42
|
| Rate for Payer: Anthem Medicaid |
$271.76
|
| Rate for Payer: Buckeye Individual/Medicaid |
$257.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$257.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$308.78
|
| Rate for Payer: Cash Price |
$3,556.50
|
| Rate for Payer: Cash Price |
$3,556.50
|
| Rate for Payer: Cigna Commercial |
$408.11
|
| Rate for Payer: Healthspan PPO |
$569.65
|
| Rate for Payer: Humana Medicaid |
$271.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$375.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$257.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$277.20
|
| Rate for Payer: Molina Healthcare Passport |
$271.76
|
| Rate for Payer: Multiplan PHCS |
$4,267.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$334.52
|
| Rate for Payer: UHCCP Medicaid |
$165.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$274.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$257.32
|
|
|
CYSTO W/COMP RMV STONE/STENT
|
Facility
|
OP
|
$7,113.00
|
|
|
Service Code
|
HCPCS 52315
|
| Hospital Charge Code |
76102097
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$6,828.48 |
| Rate for Payer: Aetna Commercial |
$5,477.01
|
| Rate for Payer: Anthem Medicaid |
$2,446.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,548.14
|
| 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 |
$3,556.50
|
| Rate for Payer: Cash Price |
$3,556.50
|
| Rate for Payer: Cigna Commercial |
$5,903.79
|
| Rate for Payer: First Health Commercial |
$6,757.35
|
| Rate for Payer: Humana Commercial |
$6,046.05
|
| Rate for Payer: Humana KY Medicaid |
$2,446.16
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,471.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,832.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,249.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,495.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,259.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,334.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,690.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,188.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,907.97
|
| Rate for Payer: PHCS Commercial |
$6,828.48
|
| Rate for Payer: United Healthcare All Payer |
$6,259.44
|
|
|
CYSTO W/COMP RMV STONE/STENT
|
Facility
|
IP
|
$7,113.00
|
|
|
Service Code
|
HCPCS 52315
|
| Hospital Charge Code |
76102097
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,133.90 |
| Max. Negotiated Rate |
$6,828.48 |
| Rate for Payer: Aetna Commercial |
$5,477.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,548.14
|
| Rate for Payer: Cash Price |
$3,556.50
|
| Rate for Payer: Cigna Commercial |
$5,903.79
|
| Rate for Payer: First Health Commercial |
$6,757.35
|
| Rate for Payer: Humana Commercial |
$6,046.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,832.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,249.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,133.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,259.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,334.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,690.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,188.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,907.97
|
| Rate for Payer: PHCS Commercial |
$6,828.48
|
| Rate for Payer: United Healthcare All Payer |
$6,259.44
|
|
|
CYSTO W/COMP RMV STONE/STENT(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 52315
|
| Hospital Charge Code |
761P2097
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.42 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$457.67
|
| Rate for Payer: Ambetter Exchange |
$257.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$157.42
|
| Rate for Payer: Anthem Medicaid |
$271.76
|
| Rate for Payer: Buckeye Individual/Medicaid |
$257.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$257.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$308.78
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$408.11
|
| Rate for Payer: Healthspan PPO |
$569.65
|
| Rate for Payer: Humana Medicaid |
$271.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$375.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$257.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$277.20
|
| Rate for Payer: Molina Healthcare Passport |
$271.76
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$334.52
|
| Rate for Payer: UHCCP Medicaid |
$165.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$274.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$257.32
|
|
|
CYSTO W/COMP RMV STONE/STENT(T
|
Facility
|
IP
|
$5,913.00
|
|
|
Service Code
|
HCPCS 52315
|
| Hospital Charge Code |
761T2097
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,773.90 |
| Max. Negotiated Rate |
$5,676.48 |
| Rate for Payer: Aetna Commercial |
$4,553.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,612.14
|
| Rate for Payer: Cash Price |
$2,956.50
|
| Rate for Payer: Cigna Commercial |
$4,907.79
|
| Rate for Payer: First Health Commercial |
$5,617.35
|
| Rate for Payer: Humana Commercial |
$5,026.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,848.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,363.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,773.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,203.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,434.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,730.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,144.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,079.97
|
| Rate for Payer: PHCS Commercial |
$5,676.48
|
| Rate for Payer: United Healthcare All Payer |
$5,203.44
|
|
|
CYSTO W/COMP RMV STONE/STENT(T
|
Facility
|
OP
|
$5,913.00
|
|
|
Service Code
|
HCPCS 52315
|
| Hospital Charge Code |
761T2097
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,676.48 |
| Rate for Payer: Aetna Commercial |
$4,553.01
|
| Rate for Payer: Anthem Medicaid |
$2,033.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,612.14
|
| 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 |
$2,956.50
|
| Rate for Payer: Cash Price |
$2,956.50
|
| Rate for Payer: Cigna Commercial |
$4,907.79
|
| Rate for Payer: First Health Commercial |
$5,617.35
|
| Rate for Payer: Humana Commercial |
$5,026.05
|
| Rate for Payer: Humana KY Medicaid |
$2,033.48
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,054.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,848.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,363.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,074.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,203.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,434.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,730.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,144.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,079.97
|
| Rate for Payer: PHCS Commercial |
$5,676.48
|
| Rate for Payer: United Healthcare All Payer |
$5,203.44
|
|
|
CYSTO W/DESTRUCTION OF LESIONS
|
Facility
|
IP
|
$5,138.17
|
|
|
Service Code
|
HCPCS 52214
|
| Hospital Charge Code |
761T2085
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,541.45 |
| Max. Negotiated Rate |
$4,932.64 |
| Rate for Payer: Aetna Commercial |
$3,956.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,007.77
|
| Rate for Payer: Cash Price |
$2,569.08
|
| Rate for Payer: Cigna Commercial |
$4,264.68
|
| Rate for Payer: First Health Commercial |
$4,881.26
|
| Rate for Payer: Humana Commercial |
$4,367.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,213.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,791.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,541.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,521.59
|
| Rate for Payer: Ohio Health Group HMO |
$3,853.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,110.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,470.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,545.34
|
| Rate for Payer: PHCS Commercial |
$4,932.64
|
| Rate for Payer: United Healthcare All Payer |
$4,521.59
|
|
|
CYSTO W/DESTRUCTION OF LESIONS
|
Facility
|
OP
|
$5,138.17
|
|
|
Service Code
|
HCPCS 52214
|
| Hospital Charge Code |
761T2085
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,767.02 |
| Max. Negotiated Rate |
$4,932.64 |
| Rate for Payer: Aetna Commercial |
$3,956.39
|
| Rate for Payer: Anthem Medicaid |
$1,767.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,007.77
|
| 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 |
$2,569.08
|
| Rate for Payer: Cash Price |
$2,569.08
|
| Rate for Payer: Cigna Commercial |
$4,264.68
|
| Rate for Payer: First Health Commercial |
$4,881.26
|
| Rate for Payer: Humana Commercial |
$4,367.44
|
| Rate for Payer: Humana KY Medicaid |
$1,767.02
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,785.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,213.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,791.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,802.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,521.59
|
| Rate for Payer: Ohio Health Group HMO |
$3,853.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,110.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,470.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,545.34
|
| Rate for Payer: PHCS Commercial |
$4,932.64
|
| Rate for Payer: United Healthcare All Payer |
$4,521.59
|
|
|
CYSTO W/DESTRUCTION OF LESIONS
|
Professional
|
Both
|
$1,975.00
|
|
|
Service Code
|
HCPCS 52214
|
| Hospital Charge Code |
761P2085
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.44 |
| Max. Negotiated Rate |
$1,185.00 |
| Rate for Payer: Aetna Commercial |
$358.42
|
| Rate for Payer: Ambetter Exchange |
$165.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$137.44
|
| Rate for Payer: Anthem Medicaid |
$190.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$165.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$165.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$198.00
|
| Rate for Payer: Cash Price |
$987.50
|
| Rate for Payer: Cash Price |
$987.50
|
| Rate for Payer: Cigna Commercial |
$292.39
|
| Rate for Payer: Healthspan PPO |
$723.97
|
| Rate for Payer: Humana Medicaid |
$190.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$165.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$194.59
|
| Rate for Payer: Molina Healthcare Passport |
$190.77
|
| Rate for Payer: Multiplan PHCS |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$214.50
|
| Rate for Payer: UHCCP Medicaid |
$144.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$165.00
|
|
|
CYSTO W/DESTRUCTION OF LESIONS
|
Facility
|
OP
|
$7,113.17
|
|
|
Service Code
|
HCPCS 52214
|
| Hospital Charge Code |
76102085
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,446.22 |
| Max. Negotiated Rate |
$6,828.64 |
| Rate for Payer: Aetna Commercial |
$5,477.14
|
| Rate for Payer: Anthem Medicaid |
$2,446.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,548.27
|
| 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 |
$3,556.58
|
| Rate for Payer: Cash Price |
$3,556.58
|
| Rate for Payer: Cigna Commercial |
$5,903.93
|
| Rate for Payer: First Health Commercial |
$6,757.51
|
| Rate for Payer: Humana Commercial |
$6,046.19
|
| Rate for Payer: Humana KY Medicaid |
$2,446.22
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,471.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,832.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,249.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,495.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,259.59
|
| Rate for Payer: Ohio Health Group HMO |
$5,334.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,690.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,188.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,908.09
|
| Rate for Payer: PHCS Commercial |
$6,828.64
|
| Rate for Payer: United Healthcare All Payer |
$6,259.59
|
|
