|
DILATOR RENAL AMPLATZ 14*8
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 18*8
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 18*8
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 22*8
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 22*8
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 24FR
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 24FR
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 26*8
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 26*8
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 28FR
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 28FR
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 30FR
|
Facility
|
IP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILATOR RENAL AMPLATZ 30FR
|
Facility
|
OP
|
$793.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$761.76 |
| Rate for Payer: Aetna Commercial |
$611.00
|
| Rate for Payer: Anthem Medicaid |
$272.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$618.93
|
| Rate for Payer: Cash Price |
$396.75
|
| Rate for Payer: Cigna Commercial |
$658.61
|
| Rate for Payer: First Health Commercial |
$753.83
|
| Rate for Payer: Humana Commercial |
$674.48
|
| Rate for Payer: Humana KY Medicaid |
$272.88
|
| Rate for Payer: Kentucky WC Medicaid |
$275.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$650.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$585.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$698.28
|
| Rate for Payer: Ohio Health Group HMO |
$595.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$634.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.51
|
| Rate for Payer: PHCS Commercial |
$761.76
|
| Rate for Payer: United Healthcare All Payer |
$698.28
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$952.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
76102117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$40.94 |
| Max. Negotiated Rate |
$571.20 |
| Rate for Payer: Aetna Commercial |
$106.77
|
| Rate for Payer: Ambetter Exchange |
$60.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$40.94
|
| Rate for Payer: Anthem Medicaid |
$45.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$60.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$72.48
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cigna Commercial |
$132.86
|
| Rate for Payer: Healthspan PPO |
$111.05
|
| Rate for Payer: Humana Medicaid |
$45.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$60.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.99
|
| Rate for Payer: Molina Healthcare Passport |
$45.09
|
| Rate for Payer: Multiplan PHCS |
$571.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.52
|
| Rate for Payer: UHCCP Medicaid |
$42.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$60.40
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$620.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
76102120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$67.57
|
| Rate for Payer: Ambetter Exchange |
$38.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.20
|
| Rate for Payer: Anthem Medicaid |
$29.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.68
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$112.85
|
| Rate for Payer: Healthspan PPO |
$92.11
|
| Rate for Payer: Humana Medicaid |
$29.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$56.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.65
|
| Rate for Payer: Molina Healthcare Passport |
$29.07
|
| Rate for Payer: Multiplan PHCS |
$372.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.57
|
| Rate for Payer: UHCCP Medicaid |
$26.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.90
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$620.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
76102120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$595.20 |
| Rate for Payer: Aetna Commercial |
$477.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.60
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$514.60
|
| Rate for Payer: First Health Commercial |
$589.00
|
| Rate for Payer: Humana Commercial |
$527.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.60
|
| Rate for Payer: Ohio Health Group HMO |
$465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.80
|
| Rate for Payer: PHCS Commercial |
$595.20
|
| Rate for Payer: United Healthcare All Payer |
$545.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$620.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
76102120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$595.20 |
| Rate for Payer: Aetna Commercial |
$477.40
|
| Rate for Payer: Anthem Medicaid |
$213.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$514.60
|
| Rate for Payer: First Health Commercial |
$589.00
|
| Rate for Payer: Humana Commercial |
$527.00
|
| Rate for Payer: Humana KY Medicaid |
$213.22
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$215.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.60
|
| Rate for Payer: Ohio Health Group HMO |
$465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.80
|
| Rate for Payer: PHCS Commercial |
$595.20
|
| Rate for Payer: United Healthcare All Payer |
$545.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$952.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
76102117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$913.92 |
| Rate for Payer: Aetna Commercial |
$733.04
|
| Rate for Payer: Anthem Medicaid |
$327.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$742.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cigna Commercial |
$790.16
|
| Rate for Payer: First Health Commercial |
$904.40
|
| Rate for Payer: Humana Commercial |
$809.20
|
| Rate for Payer: Humana KY Medicaid |
$327.39
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$330.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$780.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$702.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$333.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$837.76
|
| Rate for Payer: Ohio Health Group HMO |
$714.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$761.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$828.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$656.88
|
| Rate for Payer: PHCS Commercial |
$913.92
|
| Rate for Payer: United Healthcare All Payer |
$837.76
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
761P2117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$40.94 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$106.77
|
| Rate for Payer: Ambetter Exchange |
$60.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$40.94
|
| Rate for Payer: Anthem Medicaid |
$45.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$60.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$72.48
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$132.86
|
| Rate for Payer: Healthspan PPO |
$111.05
|
| Rate for Payer: Humana Medicaid |
$45.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$60.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.99
|
| Rate for Payer: Molina Healthcare Passport |
$45.09
|
| Rate for Payer: Multiplan PHCS |
$159.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.52
|
| Rate for Payer: UHCCP Medicaid |
$42.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$60.40
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$952.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
76102117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.60 |
| Max. Negotiated Rate |
$913.92 |
| Rate for Payer: Aetna Commercial |
$733.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$742.56
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cigna Commercial |
$790.16
|
| Rate for Payer: First Health Commercial |
$904.40
|
| Rate for Payer: Humana Commercial |
$809.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$780.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$702.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$285.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$837.76
|
| Rate for Payer: Ohio Health Group HMO |
$714.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$761.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$828.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$656.88
|
| Rate for Payer: PHCS Commercial |
$913.92
|
| Rate for Payer: United Healthcare All Payer |
$837.76
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
761T2120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$687.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
761T2117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$206.10 |
| Max. Negotiated Rate |
$659.52 |
| Rate for Payer: Aetna Commercial |
$528.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$535.86
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$570.21
|
| Rate for Payer: First Health Commercial |
$652.65
|
| Rate for Payer: Humana Commercial |
$583.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$563.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$507.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$604.56
|
| Rate for Payer: Ohio Health Group HMO |
$515.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$549.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$597.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.03
|
| Rate for Payer: PHCS Commercial |
$659.52
|
| Rate for Payer: United Healthcare All Payer |
$604.56
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
761T2120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.26 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem Medicaid |
$84.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Humana KY Medicaid |
$84.26
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$85.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$687.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
761T2117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$659.52 |
| Rate for Payer: Aetna Commercial |
$528.99
|
| Rate for Payer: Anthem Medicaid |
$236.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$535.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$570.21
|
| Rate for Payer: First Health Commercial |
$652.65
|
| Rate for Payer: Humana Commercial |
$583.95
|
| Rate for Payer: Humana KY Medicaid |
$236.26
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$238.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$563.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$507.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$241.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$604.56
|
| Rate for Payer: Ohio Health Group HMO |
$515.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$549.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$597.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.03
|
| Rate for Payer: PHCS Commercial |
$659.52
|
| Rate for Payer: United Healthcare All Payer |
$604.56
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
761P2120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna Commercial |
$67.57
|
| Rate for Payer: Ambetter Exchange |
$38.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.20
|
| Rate for Payer: Anthem Medicaid |
$29.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.68
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$112.85
|
| Rate for Payer: Healthspan PPO |
$92.11
|
| Rate for Payer: Humana Medicaid |
$29.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$56.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.65
|
| Rate for Payer: Molina Healthcare Passport |
$29.07
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.57
|
| Rate for Payer: UHCCP Medicaid |
$26.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.90
|
|
