|
CYSTO W/RENAL STRICTURE TX
|
Facility
|
IP
|
$838.00
|
|
|
Service Code
|
HCPCS 52343
|
| Hospital Charge Code |
76102894
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$251.40 |
| Max. Negotiated Rate |
$804.48 |
| Rate for Payer: Aetna Commercial |
$645.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$653.64
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$695.54
|
| Rate for Payer: First Health Commercial |
$796.10
|
| Rate for Payer: Humana Commercial |
$712.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$618.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$737.44
|
| Rate for Payer: Ohio Health Group HMO |
$628.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$670.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$578.22
|
| Rate for Payer: PHCS Commercial |
$804.48
|
| Rate for Payer: United Healthcare All Payer |
$737.44
|
|
|
CYSTO W/SIMPLE RMV STONE/STENT
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
761P2096
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.50 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$251.39
|
| Rate for Payer: Ambetter Exchange |
$142.66
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.50
|
| Rate for Payer: Anthem Medicaid |
$169.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$142.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$142.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.19
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$410.50
|
| Rate for Payer: Healthspan PPO |
$321.27
|
| Rate for Payer: Humana Medicaid |
$169.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$208.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$142.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$173.34
|
| Rate for Payer: Molina Healthcare Passport |
$169.94
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$185.46
|
| Rate for Payer: UHCCP Medicaid |
$109.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$142.66
|
|
|
CYSTO W/SIMPLE RMV STONE/STENT
|
Facility
|
IP
|
$5,132.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
761T2096
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,539.60 |
| Max. Negotiated Rate |
$4,926.72 |
| Rate for Payer: Aetna Commercial |
$3,951.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,002.96
|
| Rate for Payer: Cash Price |
$2,566.00
|
| Rate for Payer: Cigna Commercial |
$4,259.56
|
| Rate for Payer: First Health Commercial |
$4,875.40
|
| Rate for Payer: Humana Commercial |
$4,362.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,208.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,787.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,539.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,516.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,105.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,464.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,541.08
|
| Rate for Payer: PHCS Commercial |
$4,926.72
|
| Rate for Payer: United Healthcare All Payer |
$4,516.16
|
|
|
CYSTO W/SIMPLE RMV STONE/STENT
|
Facility
|
OP
|
$5,132.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
761T2096
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,764.89 |
| Max. Negotiated Rate |
$4,926.72 |
| Rate for Payer: Aetna Commercial |
$3,951.64
|
| Rate for Payer: Anthem Medicaid |
$1,764.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,002.96
|
| 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 |
$2,566.00
|
| Rate for Payer: Cash Price |
$2,566.00
|
| Rate for Payer: Cigna Commercial |
$4,259.56
|
| Rate for Payer: First Health Commercial |
$4,875.40
|
| Rate for Payer: Humana Commercial |
$4,362.20
|
| Rate for Payer: Humana KY Medicaid |
$1,764.89
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,782.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,208.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,787.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,800.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,516.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,105.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,464.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,541.08
|
| Rate for Payer: PHCS Commercial |
$4,926.72
|
| Rate for Payer: United Healthcare All Payer |
$4,516.16
|
|
|
CYSTO W/SIMPLE RMV STONE/STENT
|
Professional
|
Both
|
$5,932.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
76102096
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.50 |
| Max. Negotiated Rate |
$3,559.20 |
| Rate for Payer: Aetna Commercial |
$251.39
|
| Rate for Payer: Ambetter Exchange |
$142.66
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.50
|
| Rate for Payer: Anthem Medicaid |
$169.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$142.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$142.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.19
|
| Rate for Payer: Cash Price |
$2,966.00
|
| Rate for Payer: Cash Price |
$2,966.00
|
| Rate for Payer: Cigna Commercial |
$410.50
|
| Rate for Payer: Healthspan PPO |
$321.27
|
| Rate for Payer: Humana Medicaid |
$169.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$208.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$142.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$173.34
|
| Rate for Payer: Molina Healthcare Passport |
$169.94
|
| Rate for Payer: Multiplan PHCS |
$3,559.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$185.46
|
| Rate for Payer: UHCCP Medicaid |
$109.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$142.66
|
|
|
CYSTO W/SIMPLE RMV STONE/STENT
|
Facility
|
IP
|
$5,932.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
76102096
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,779.60 |
| Max. Negotiated Rate |
$5,694.72 |
| Rate for Payer: Aetna Commercial |
$4,567.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,626.96
|
| Rate for Payer: Cash Price |
$2,966.00
|
| Rate for Payer: Cigna Commercial |
$4,923.56
|
| Rate for Payer: First Health Commercial |
$5,635.40
|
| Rate for Payer: Humana Commercial |
$5,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,864.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,377.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,779.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,220.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,449.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,745.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,160.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,093.08
|
| Rate for Payer: PHCS Commercial |
$5,694.72
|
| Rate for Payer: United Healthcare All Payer |
$5,220.16
|
|
|
CYSTO W/SIMPLE RMV STONE/STENT
|
Facility
|
OP
|
$5,932.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
76102096
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,694.72 |
| Rate for Payer: Aetna Commercial |
$4,567.64
|
| Rate for Payer: Anthem Medicaid |
$2,040.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,626.96
|
| 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 |
$2,966.00
|
| Rate for Payer: Cash Price |
$2,966.00
|
| Rate for Payer: Cigna Commercial |
$4,923.56
|
| Rate for Payer: First Health Commercial |
$5,635.40
|
| Rate for Payer: Humana Commercial |
$5,042.20
|
| Rate for Payer: Humana KY Medicaid |
$2,040.01
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,060.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,864.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,377.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,080.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,220.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,449.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,745.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,160.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,093.08
|
| Rate for Payer: PHCS Commercial |
$5,694.72
|
| Rate for Payer: United Healthcare All Payer |
$5,220.16
|
|
|
CYSTO W/TX URETERAL STRICTURE
|
Facility
|
OP
|
$4,998.00
|
|
|
Service Code
|
HCPCS 52341
|
| Hospital Charge Code |
76102104
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,718.81 |
| Max. Negotiated Rate |
$4,798.08 |
| Rate for Payer: Aetna Commercial |
$3,848.46
|
| Rate for Payer: Anthem Medicaid |
$1,718.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,898.44
|
| 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 |
$2,499.00
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cigna Commercial |
$4,148.34
|
| Rate for Payer: First Health Commercial |
$4,748.10
|
| Rate for Payer: Humana Commercial |
$4,248.30
|
| Rate for Payer: Humana KY Medicaid |
$1,718.81
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,736.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,098.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,688.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,753.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,398.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,748.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,998.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,348.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,448.62
|
| Rate for Payer: PHCS Commercial |
$4,798.08
|
| Rate for Payer: United Healthcare All Payer |
$4,398.24
|
|
|
CYSTO W/TX URETERAL STRICTURE
|
Professional
|
Both
|
$4,998.00
|
|
|
Service Code
|
HCPCS 52341
|
| Hospital Charge Code |
76102104
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.12 |
| Max. Negotiated Rate |
$2,998.80 |
| Rate for Payer: Aetna Commercial |
$486.66
|
| Rate for Payer: Ambetter Exchange |
$266.05
|
| Rate for Payer: Anthem Medicaid |
$243.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$266.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$266.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.26
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cigna Commercial |
$483.62
|
| Rate for Payer: Healthspan PPO |
$389.13
|
| Rate for Payer: Humana Medicaid |
$243.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$266.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$247.98
|
| Rate for Payer: Molina Healthcare Passport |
$243.12
|
| Rate for Payer: Multiplan PHCS |
$2,998.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$345.87
|
| Rate for Payer: UHCCP Medicaid |
$1,749.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$245.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$266.05
|
|
|
CYSTO W/TX URETERAL STRICTURE
|
Facility
|
IP
|
$4,998.00
|
|
|
Service Code
|
HCPCS 52341
|
| Hospital Charge Code |
76102104
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,499.40 |
| Max. Negotiated Rate |
$4,798.08 |
| Rate for Payer: Aetna Commercial |
$3,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,898.44
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cigna Commercial |
$4,148.34
|
| Rate for Payer: First Health Commercial |
$4,748.10
|
| Rate for Payer: Humana Commercial |
$4,248.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,098.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,688.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,499.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,398.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,748.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,998.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,348.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,448.62
|
| Rate for Payer: PHCS Commercial |
$4,798.08
|
| Rate for Payer: United Healthcare All Payer |
$4,398.24
|
|
|
CYSTO W/TX URETERAL STRICTUR(P
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
HCPCS 52341
|
| Hospital Charge Code |
761P2104
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$486.66 |
| Rate for Payer: Aetna Commercial |
$486.66
|
| Rate for Payer: Ambetter Exchange |
$266.05
|
| Rate for Payer: Anthem Medicaid |
$243.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$266.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$266.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.26
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$483.62
|
| Rate for Payer: Healthspan PPO |
$389.13
|
| Rate for Payer: Humana Medicaid |
$243.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$266.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$247.98
|
| Rate for Payer: Molina Healthcare Passport |
$243.12
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$345.87
|
| Rate for Payer: UHCCP Medicaid |
$236.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$245.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$266.05
|
|
|
CYSTO W/TX URETERAL STRICTUR(T
|
Facility
|
IP
|
$4,323.00
|
|
|
Service Code
|
HCPCS 52341
|
| Hospital Charge Code |
761T2104
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,296.90 |
| Max. Negotiated Rate |
$4,150.08 |
| Rate for Payer: Aetna Commercial |
$3,328.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,371.94
|
| Rate for Payer: Cash Price |
$2,161.50
|
| Rate for Payer: Cigna Commercial |
$3,588.09
|
| Rate for Payer: First Health Commercial |
$4,106.85
|
| Rate for Payer: Humana Commercial |
$3,674.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,544.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,190.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,296.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,804.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,242.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,458.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,761.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,982.87
|
| Rate for Payer: PHCS Commercial |
$4,150.08
|
| Rate for Payer: United Healthcare All Payer |
$3,804.24
|
|
|
CYSTO W/TX URETERAL STRICTUR(T
|
Facility
|
OP
|
$4,323.00
|
|
|
Service Code
|
HCPCS 52341
|
| Hospital Charge Code |
761T2104
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,486.68 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Aetna Commercial |
$3,328.71
|
| Rate for Payer: Anthem Medicaid |
$1,486.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,371.94
|
| 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 |
$2,161.50
|
| Rate for Payer: Cash Price |
$2,161.50
|
| Rate for Payer: Cigna Commercial |
$3,588.09
|
| Rate for Payer: First Health Commercial |
$4,106.85
|
| Rate for Payer: Humana Commercial |
$3,674.55
|
| Rate for Payer: Humana KY Medicaid |
$1,486.68
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,501.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,544.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,190.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,516.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,804.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,242.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,458.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,761.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,982.87
|
| Rate for Payer: PHCS Commercial |
$4,150.08
|
| Rate for Payer: United Healthcare All Payer |
$3,804.24
|
|
|
CYSTO W/URETEROSCOPY W/LITHO(P
|
Professional
|
Both
|
$975.00
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
761P2108
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$341.25 |
| Max. Negotiated Rate |
$706.19 |
| Rate for Payer: Aetna Commercial |
$706.19
|
| Rate for Payer: Ambetter Exchange |
$366.93
|
| Rate for Payer: Anthem Medicaid |
$353.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$366.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$366.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$440.32
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$628.17
|
| Rate for Payer: Healthspan PPO |
$564.66
|
| Rate for Payer: Humana Medicaid |
$353.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$580.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$366.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$366.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$360.50
|
| Rate for Payer: Molina Healthcare Passport |
$353.43
|
| Rate for Payer: Multiplan PHCS |
$585.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$477.01
|
| Rate for Payer: UHCCP Medicaid |
$341.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$356.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$366.93
|
|
|
CYSTO W/URETEROSCOPY W/LITHO(T
|
Facility
|
OP
|
$8,131.40
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
761T2108
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,796.39 |
| Max. Negotiated Rate |
$7,806.14 |
| Rate for Payer: Aetna Commercial |
$6,261.18
|
| Rate for Payer: Anthem Medicaid |
$2,796.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,342.49
|
| 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 |
$4,065.70
|
| Rate for Payer: Cash Price |
$4,065.70
|
| Rate for Payer: Cigna Commercial |
$6,749.06
|
| Rate for Payer: First Health Commercial |
$7,724.83
|
| Rate for Payer: Humana Commercial |
$6,911.69
|
| Rate for Payer: Humana KY Medicaid |
$2,796.39
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,824.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,667.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,000.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,852.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,155.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,098.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,505.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,074.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,610.67
|
| Rate for Payer: PHCS Commercial |
$7,806.14
|
| Rate for Payer: United Healthcare All Payer |
$7,155.63
|
|
|
CYSTO W/URETEROSCOPY W/LITHO(T
|
Facility
|
IP
|
$8,131.40
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
761T2108
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,439.42 |
| Max. Negotiated Rate |
$7,806.14 |
| Rate for Payer: Aetna Commercial |
$6,261.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,342.49
|
| Rate for Payer: Cash Price |
$4,065.70
|
| Rate for Payer: Cigna Commercial |
$6,749.06
|
| Rate for Payer: First Health Commercial |
$7,724.83
|
| Rate for Payer: Humana Commercial |
$6,911.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,667.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,000.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,439.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,155.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,098.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,505.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,074.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,610.67
|
| Rate for Payer: PHCS Commercial |
$7,806.14
|
| Rate for Payer: United Healthcare All Payer |
$7,155.63
|
|
|
CYSTO W/URETEROSCOPY W/LITHOT
|
Facility
|
OP
|
$9,106.40
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
76102108
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$3,131.69 |
| Max. Negotiated Rate |
$8,742.14 |
| Rate for Payer: Aetna Commercial |
$7,011.93
|
| Rate for Payer: Anthem Medicaid |
$3,131.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,102.99
|
| 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 |
$4,553.20
|
| Rate for Payer: Cash Price |
$4,553.20
|
| Rate for Payer: Cigna Commercial |
$7,558.31
|
| Rate for Payer: First Health Commercial |
$8,651.08
|
| Rate for Payer: Humana Commercial |
$7,740.44
|
| Rate for Payer: Humana KY Medicaid |
$3,131.69
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,163.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,467.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,720.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,194.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,013.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,829.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,285.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,922.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,283.42
|
| Rate for Payer: PHCS Commercial |
$8,742.14
|
| Rate for Payer: United Healthcare All Payer |
$8,013.63
|
|
|
CYSTO W/URETEROSCOPY W/LITHOT
|
Professional
|
Both
|
$9,106.40
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
76102108
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$353.43 |
| Max. Negotiated Rate |
$5,463.84 |
| Rate for Payer: Aetna Commercial |
$706.19
|
| Rate for Payer: Ambetter Exchange |
$366.93
|
| Rate for Payer: Anthem Medicaid |
$353.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$366.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$366.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$440.32
|
| Rate for Payer: Cash Price |
$4,553.20
|
| Rate for Payer: Cash Price |
$4,553.20
|
| Rate for Payer: Cigna Commercial |
$628.17
|
| Rate for Payer: Healthspan PPO |
$564.66
|
| Rate for Payer: Humana Medicaid |
$353.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$580.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$366.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$366.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$360.50
|
| Rate for Payer: Molina Healthcare Passport |
$353.43
|
| Rate for Payer: Multiplan PHCS |
$5,463.84
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$477.01
|
| Rate for Payer: UHCCP Medicaid |
$3,187.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$356.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$366.93
|
|
|
CYSTO W/URETEROSCOPY W/LITHOT
|
Facility
|
IP
|
$9,106.40
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
76102108
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,731.92 |
| Max. Negotiated Rate |
$8,742.14 |
| Rate for Payer: Aetna Commercial |
$7,011.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,102.99
|
| Rate for Payer: Cash Price |
$4,553.20
|
| Rate for Payer: Cigna Commercial |
$7,558.31
|
| Rate for Payer: First Health Commercial |
$8,651.08
|
| Rate for Payer: Humana Commercial |
$7,740.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,467.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,720.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,731.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,013.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,829.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,285.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,922.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,283.42
|
| Rate for Payer: PHCS Commercial |
$8,742.14
|
| Rate for Payer: United Healthcare All Payer |
$8,013.63
|
|
|
CYSTO W/URTROSCOP/PYELOSCOP DX
|
Facility
|
OP
|
$5,618.67
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
76102106
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,932.26 |
| Max. Negotiated Rate |
$5,393.92 |
| Rate for Payer: Aetna Commercial |
$4,326.38
|
| Rate for Payer: Anthem Medicaid |
$1,932.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,382.56
|
| 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 |
$2,809.34
|
| Rate for Payer: Cash Price |
$2,809.34
|
| Rate for Payer: Cigna Commercial |
$4,663.50
|
| Rate for Payer: First Health Commercial |
$5,337.74
|
| Rate for Payer: Humana Commercial |
$4,775.87
|
| Rate for Payer: Humana KY Medicaid |
$1,932.26
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,951.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,607.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,146.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,971.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,944.43
|
| Rate for Payer: Ohio Health Group HMO |
$4,214.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,494.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,888.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,876.88
|
| Rate for Payer: PHCS Commercial |
$5,393.92
|
| Rate for Payer: United Healthcare All Payer |
$4,944.43
|
|
|
CYSTO W/URTROSCOP/PYELOSCOP DX
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
761P2106
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.37 |
| Max. Negotiated Rate |
$522.14 |
| Rate for Payer: Aetna Commercial |
$522.14
|
| Rate for Payer: Ambetter Exchange |
$284.27
|
| Rate for Payer: Anthem Medicaid |
$247.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$284.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$284.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$341.12
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$463.92
|
| Rate for Payer: Healthspan PPO |
$417.50
|
| Rate for Payer: Humana Medicaid |
$247.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$429.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$284.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$252.32
|
| Rate for Payer: Molina Healthcare Passport |
$247.37
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.55
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$249.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$284.27
|
|
|
CYSTO W/URTROSCOP/PYELOSCOP DX
|
Facility
|
OP
|
$4,818.67
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
761T2106
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,657.14 |
| Max. Negotiated Rate |
$4,625.92 |
| Rate for Payer: Aetna Commercial |
$3,710.38
|
| Rate for Payer: Anthem Medicaid |
$1,657.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,758.56
|
| 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 |
$2,409.34
|
| Rate for Payer: Cash Price |
$2,409.34
|
| Rate for Payer: Cigna Commercial |
$3,999.50
|
| Rate for Payer: First Health Commercial |
$4,577.74
|
| Rate for Payer: Humana Commercial |
$4,095.87
|
| Rate for Payer: Humana KY Medicaid |
$1,657.14
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,674.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,951.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,556.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,690.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,240.43
|
| Rate for Payer: Ohio Health Group HMO |
$3,614.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,854.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,192.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,324.88
|
| Rate for Payer: PHCS Commercial |
$4,625.92
|
| Rate for Payer: United Healthcare All Payer |
$4,240.43
|
|
|
CYSTO W/URTROSCOP/PYELOSCOP DX
|
Facility
|
IP
|
$5,618.67
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
76102106
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,685.60 |
| Max. Negotiated Rate |
$5,393.92 |
| Rate for Payer: Aetna Commercial |
$4,326.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,382.56
|
| Rate for Payer: Cash Price |
$2,809.34
|
| Rate for Payer: Cigna Commercial |
$4,663.50
|
| Rate for Payer: First Health Commercial |
$5,337.74
|
| Rate for Payer: Humana Commercial |
$4,775.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,607.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,146.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,685.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,944.43
|
| Rate for Payer: Ohio Health Group HMO |
$4,214.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,494.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,888.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,876.88
|
| Rate for Payer: PHCS Commercial |
$5,393.92
|
| Rate for Payer: United Healthcare All Payer |
$4,944.43
|
|
|
CYSTO W/URTROSCOP/PYELOSCOP DX
|
Professional
|
Both
|
$5,618.67
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
76102106
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.37 |
| Max. Negotiated Rate |
$3,371.20 |
| Rate for Payer: Aetna Commercial |
$522.14
|
| Rate for Payer: Ambetter Exchange |
$284.27
|
| Rate for Payer: Anthem Medicaid |
$247.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$284.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$284.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$341.12
|
| Rate for Payer: Cash Price |
$2,809.34
|
| Rate for Payer: Cash Price |
$2,809.34
|
| Rate for Payer: Cigna Commercial |
$463.92
|
| Rate for Payer: Healthspan PPO |
$417.50
|
| Rate for Payer: Humana Medicaid |
$247.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$429.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$284.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$252.32
|
| Rate for Payer: Molina Healthcare Passport |
$247.37
|
| Rate for Payer: Multiplan PHCS |
$3,371.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.55
|
| Rate for Payer: UHCCP Medicaid |
$1,966.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$249.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$284.27
|
|
|
CYSTO W/URTROSCOP/PYELOSCOP DX
|
Facility
|
IP
|
$4,818.67
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
761T2106
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,445.60 |
| Max. Negotiated Rate |
$4,625.92 |
| Rate for Payer: Aetna Commercial |
$3,710.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,758.56
|
| Rate for Payer: Cash Price |
$2,409.34
|
| Rate for Payer: Cigna Commercial |
$3,999.50
|
| Rate for Payer: First Health Commercial |
$4,577.74
|
| Rate for Payer: Humana Commercial |
$4,095.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,951.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,556.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,445.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,240.43
|
| Rate for Payer: Ohio Health Group HMO |
$3,614.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,854.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,192.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,324.88
|
| Rate for Payer: PHCS Commercial |
$4,625.92
|
| Rate for Payer: United Healthcare All Payer |
$4,240.43
|
|
