|
PET CT SKULL TO THIGH
|
Facility
|
OP
|
$7,156.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
40400008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$930.28 |
| Max. Negotiated Rate |
$6,869.76 |
| Rate for Payer: Aetna Commercial |
$5,510.12
|
| Rate for Payer: Anthem Medicaid |
$2,460.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,581.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cigna Commercial |
$5,939.48
|
| Rate for Payer: First Health Commercial |
$6,798.20
|
| Rate for Payer: Humana Commercial |
$6,082.60
|
| Rate for Payer: Humana KY Medicaid |
$2,460.95
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,485.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,867.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,281.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,510.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,297.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,367.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,431.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$930.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,218.36
|
| Rate for Payer: PHCS Commercial |
$6,869.76
|
| Rate for Payer: United Healthcare All Payer |
$6,297.28
|
|
|
PET CT SKULL TO THIGH(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
404P0008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$2,081.06 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,044.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$736.80
|
| Rate for Payer: Healthspan PPO |
$1,123.01
|
| Rate for Payer: Humana Medicaid |
$1,044.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,065.45
|
| Rate for Payer: Molina Healthcare Passport |
$1,044.56
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,055.01
|
|
|
PET CT SKULL TO THIGH(T
|
Facility
|
OP
|
$6,931.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
404T0008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$901.03 |
| Max. Negotiated Rate |
$6,653.76 |
| Rate for Payer: Aetna Commercial |
$5,336.87
|
| Rate for Payer: Anthem Medicaid |
$2,383.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,406.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$3,465.50
|
| Rate for Payer: Cash Price |
$3,465.50
|
| Rate for Payer: Cigna Commercial |
$5,752.73
|
| Rate for Payer: First Health Commercial |
$6,584.45
|
| Rate for Payer: Humana Commercial |
$5,891.35
|
| Rate for Payer: Humana KY Medicaid |
$2,383.57
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,407.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,683.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,115.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,431.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,099.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,198.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,386.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$901.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,148.61
|
| Rate for Payer: PHCS Commercial |
$6,653.76
|
| Rate for Payer: United Healthcare All Payer |
$6,099.28
|
|
|
PET CT SKULL TO THIGH(T
|
Facility
|
IP
|
$6,931.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
404T0008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$901.03 |
| Max. Negotiated Rate |
$6,653.76 |
| Rate for Payer: Aetna Commercial |
$5,336.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,406.18
|
| Rate for Payer: Cash Price |
$3,465.50
|
| Rate for Payer: Cigna Commercial |
$5,752.73
|
| Rate for Payer: First Health Commercial |
$6,584.45
|
| Rate for Payer: Humana Commercial |
$5,891.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,683.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,115.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,079.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,099.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,198.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,386.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$901.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,148.61
|
| Rate for Payer: PHCS Commercial |
$6,653.76
|
| Rate for Payer: United Healthcare All Payer |
$6,099.28
|
|
|
PETIMG FDG-18 (>=45 MCI)
|
Facility
|
IP
|
$983.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
34000061
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$127.79 |
| Max. Negotiated Rate |
$943.68 |
| Rate for Payer: Aetna Commercial |
$756.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$766.74
|
| Rate for Payer: Cash Price |
$491.50
|
| Rate for Payer: Cigna Commercial |
$815.89
|
| Rate for Payer: First Health Commercial |
$933.85
|
| Rate for Payer: Humana Commercial |
$835.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$806.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$725.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$865.04
|
| Rate for Payer: Ohio Health Group HMO |
$737.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.73
|
| Rate for Payer: PHCS Commercial |
$943.68
|
| Rate for Payer: United Healthcare All Payer |
$865.04
|
|
|
PETIMG FDG-18 (>=45 MCI)
|
Facility
|
OP
|
$983.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
34000061
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$127.79 |
| Max. Negotiated Rate |
$943.68 |
| Rate for Payer: Aetna Commercial |
$756.91
|
| Rate for Payer: Anthem Medicaid |
$338.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$766.74
|
| Rate for Payer: Cash Price |
$491.50
|
| Rate for Payer: Cigna Commercial |
$815.89
|
| Rate for Payer: First Health Commercial |
$933.85
|
| Rate for Payer: Humana Commercial |
$835.55
|
| Rate for Payer: Humana KY Medicaid |
$338.05
|
| Rate for Payer: Kentucky WC Medicaid |
$341.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$806.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$725.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$344.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$865.04
|
| Rate for Payer: Ohio Health Group HMO |
$737.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.73
|
| Rate for Payer: PHCS Commercial |
$943.68
|
| Rate for Payer: United Healthcare All Payer |
$865.04
|
|
|
PET MYOCRD META SNGL STUDYW/CT
|
Facility
|
OP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78429
|
| Hospital Charge Code |
40400001
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$323.96 |
| Max. Negotiated Rate |
$2,392.32 |
| Rate for Payer: Aetna Commercial |
$1,918.84
|
| Rate for Payer: Anthem Medicaid |
$857.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,943.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cigna Commercial |
$2,068.36
|
| Rate for Payer: First Health Commercial |
$2,367.40
|
| Rate for Payer: Humana Commercial |
$2,118.20
|
| Rate for Payer: Humana KY Medicaid |
$857.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$865.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,043.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,839.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$874.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,192.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,869.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$323.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.52
|
| Rate for Payer: PHCS Commercial |
$2,392.32
|
| Rate for Payer: United Healthcare All Payer |
$2,192.96
|
|
|
PET MYOCRD META SNGL STUDYW/CT
|
Facility
|
IP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78429
|
| Hospital Charge Code |
40400001
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$323.96 |
| Max. Negotiated Rate |
$2,392.32 |
| Rate for Payer: Aetna Commercial |
$1,918.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,943.76
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cigna Commercial |
$2,068.36
|
| Rate for Payer: First Health Commercial |
$2,367.40
|
| Rate for Payer: Humana Commercial |
$2,118.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,043.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,839.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$747.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,192.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,869.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$323.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.52
|
| Rate for Payer: PHCS Commercial |
$2,392.32
|
| Rate for Payer: United Healthcare All Payer |
$2,192.96
|
|
|
PET MYOCRDRST/STRSPERFSINGW/CT
|
Professional
|
Both
|
$2,577.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
40400002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$2,577.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,577.00
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.43
|
| Rate for Payer: Multiplan PHCS |
$1,546.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,803.90
|
| Rate for Payer: UHCCP Medicaid |
$901.95
|
|
|
PET MYOCRDRST/STRSPERFSINGW/CT
|
Facility
|
OP
|
$2,577.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
40400002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$335.01 |
| Max. Negotiated Rate |
$2,473.92 |
| Rate for Payer: Aetna Commercial |
$1,984.29
|
| Rate for Payer: Anthem Medicaid |
$886.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,010.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cigna Commercial |
$2,138.91
|
| Rate for Payer: First Health Commercial |
$2,448.15
|
| Rate for Payer: Humana Commercial |
$2,190.45
|
| Rate for Payer: Humana KY Medicaid |
$886.23
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$895.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,113.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,901.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$904.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,267.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,932.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$515.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$335.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$798.87
|
| Rate for Payer: PHCS Commercial |
$2,473.92
|
| Rate for Payer: United Healthcare All Payer |
$2,267.76
|
|
|
PET MYOCRDRST/STRSPERFSINGW/CT
|
Facility
|
IP
|
$2,577.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
40400002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$335.01 |
| Max. Negotiated Rate |
$2,473.92 |
| Rate for Payer: Aetna Commercial |
$1,984.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,010.06
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cigna Commercial |
$2,138.91
|
| Rate for Payer: First Health Commercial |
$2,448.15
|
| Rate for Payer: Humana Commercial |
$2,190.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,113.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,901.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$773.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,267.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,932.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$515.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$335.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$798.87
|
| Rate for Payer: PHCS Commercial |
$2,473.92
|
| Rate for Payer: United Healthcare All Payer |
$2,267.76
|
|
|
PET MYOCRDRST/STRSPERFSW/CT (P
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
404P0002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$280.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.43
|
| Rate for Payer: Multiplan PHCS |
$168.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$196.00
|
| Rate for Payer: UHCCP Medicaid |
$98.00
|
|
|
PET MYOCRDRST/STRSPERFSW/CT (T
|
Facility
|
OP
|
$2,297.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
404T0002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$298.61 |
| Max. Negotiated Rate |
$2,205.12 |
| Rate for Payer: Aetna Commercial |
$1,768.69
|
| Rate for Payer: Anthem Medicaid |
$789.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,791.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$1,148.50
|
| Rate for Payer: Cash Price |
$1,148.50
|
| Rate for Payer: Cigna Commercial |
$1,906.51
|
| Rate for Payer: First Health Commercial |
$2,182.15
|
| Rate for Payer: Humana Commercial |
$1,952.45
|
| Rate for Payer: Humana KY Medicaid |
$789.94
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$797.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,883.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,695.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$805.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,021.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,722.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$298.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$712.07
|
| Rate for Payer: PHCS Commercial |
$2,205.12
|
| Rate for Payer: United Healthcare All Payer |
$2,021.36
|
|
|
PET MYOCRDRST/STRSPERFSW/CT (T
|
Facility
|
IP
|
$2,297.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
404T0002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$298.61 |
| Max. Negotiated Rate |
$2,205.12 |
| Rate for Payer: Aetna Commercial |
$1,768.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,791.66
|
| Rate for Payer: Cash Price |
$1,148.50
|
| Rate for Payer: Cigna Commercial |
$1,906.51
|
| Rate for Payer: First Health Commercial |
$2,182.15
|
| Rate for Payer: Humana Commercial |
$1,952.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,883.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,695.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$689.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,021.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,722.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$298.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$712.07
|
| Rate for Payer: PHCS Commercial |
$2,205.12
|
| Rate for Payer: United Healthcare All Payer |
$2,021.36
|
|
|
PET MYOP (MULTI) REST OR STRES
|
Facility
|
OP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
404T0007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.95 |
| Max. Negotiated Rate |
$6,158.40 |
| Rate for Payer: Aetna Commercial |
$4,939.55
|
| Rate for Payer: Anthem Medicaid |
$2,206.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,003.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$3,207.50
|
| Rate for Payer: Cash Price |
$3,207.50
|
| Rate for Payer: Cigna Commercial |
$5,324.45
|
| Rate for Payer: First Health Commercial |
$6,094.25
|
| Rate for Payer: Humana Commercial |
$5,452.75
|
| Rate for Payer: Humana KY Medicaid |
$2,206.12
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,228.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,260.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,734.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,250.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,645.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,811.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,283.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$833.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,988.65
|
| Rate for Payer: PHCS Commercial |
$6,158.40
|
| Rate for Payer: United Healthcare All Payer |
$5,645.20
|
|
|
PET MYOP (MULTI) REST OR STRES
|
Facility
|
IP
|
$6,590.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
40400007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$856.70 |
| Max. Negotiated Rate |
$6,326.40 |
| Rate for Payer: Aetna Commercial |
$5,074.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,140.20
|
| Rate for Payer: Cash Price |
$3,295.00
|
| Rate for Payer: Cigna Commercial |
$5,469.70
|
| Rate for Payer: First Health Commercial |
$6,260.50
|
| Rate for Payer: Humana Commercial |
$5,601.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,403.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,863.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,977.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,799.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,942.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,318.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$856.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.90
|
| Rate for Payer: PHCS Commercial |
$6,326.40
|
| Rate for Payer: United Healthcare All Payer |
$5,799.20
|
|
|
PET MYOP (MULTI) REST OR STRES
|
Facility
|
OP
|
$6,590.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
40400007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$856.70 |
| Max. Negotiated Rate |
$6,326.40 |
| Rate for Payer: Aetna Commercial |
$5,074.30
|
| Rate for Payer: Anthem Medicaid |
$2,266.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,140.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$3,295.00
|
| Rate for Payer: Cash Price |
$3,295.00
|
| Rate for Payer: Cigna Commercial |
$5,469.70
|
| Rate for Payer: First Health Commercial |
$6,260.50
|
| Rate for Payer: Humana Commercial |
$5,601.50
|
| Rate for Payer: Humana KY Medicaid |
$2,266.30
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,289.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,403.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,863.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,311.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,799.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,942.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,318.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$856.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.90
|
| Rate for Payer: PHCS Commercial |
$6,326.40
|
| Rate for Payer: United Healthcare All Payer |
$5,799.20
|
|
|
PET MYOP (MULTI) REST OR STRES
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
404P0007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$2,081.06 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$496.80
|
| Rate for Payer: Healthspan PPO |
$1,265.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.62
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
|
|
PET MYOP (MULTI) REST OR STRES
|
Facility
|
IP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
404T0007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.95 |
| Max. Negotiated Rate |
$6,158.40 |
| Rate for Payer: Aetna Commercial |
$4,939.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,003.70
|
| Rate for Payer: Cash Price |
$3,207.50
|
| Rate for Payer: Cigna Commercial |
$5,324.45
|
| Rate for Payer: First Health Commercial |
$6,094.25
|
| Rate for Payer: Humana Commercial |
$5,452.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,260.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,734.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,924.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,645.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,811.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,283.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$833.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,988.65
|
| Rate for Payer: PHCS Commercial |
$6,158.40
|
| Rate for Payer: United Healthcare All Payer |
$5,645.20
|
|
|
PET MYOP (MULTI) REST OR STRES
|
Professional
|
Both
|
$6,590.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
40400007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$109.62 |
| Max. Negotiated Rate |
$6,590.00 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,590.00
|
| Rate for Payer: Cash Price |
$3,295.00
|
| Rate for Payer: Cash Price |
$3,295.00
|
| Rate for Payer: Cigna Commercial |
$496.80
|
| Rate for Payer: Healthspan PPO |
$1,265.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.62
|
| Rate for Payer: Multiplan PHCS |
$3,954.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,613.00
|
| Rate for Payer: UHCCP Medicaid |
$2,306.50
|
|
|
PET MYOPPERFW/META RDOTRCRW/CT
|
Facility
|
OP
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$644.80 |
| Max. Negotiated Rate |
$4,761.60 |
| Rate for Payer: Aetna Commercial |
$3,819.20
|
| Rate for Payer: Anthem Medicaid |
$1,705.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,770.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,478.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,389.86
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cigna Commercial |
$4,116.80
|
| Rate for Payer: First Health Commercial |
$4,712.00
|
| Rate for Payer: Humana Commercial |
$4,216.00
|
| Rate for Payer: Humana KY Medicaid |
$1,705.74
|
| Rate for Payer: Humana Medicare Advantage |
$1,770.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,723.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,067.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,124.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,739.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$644.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,537.60
|
| Rate for Payer: PHCS Commercial |
$4,761.60
|
| Rate for Payer: United Healthcare All Payer |
$4,364.80
|
|
|
PET MYOPPERFW/META RDOTRCRW/CT
|
Professional
|
Both
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$122.62 |
| Max. Negotiated Rate |
$4,960.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,960.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.62
|
| Rate for Payer: Multiplan PHCS |
$2,976.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,472.00
|
| Rate for Payer: UHCCP Medicaid |
$1,736.00
|
|
|
PET MYOPPERFW/META RDOTRCRW/CT
|
Facility
|
IP
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$644.80 |
| Max. Negotiated Rate |
$4,761.60 |
| Rate for Payer: Aetna Commercial |
$3,819.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.80
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cigna Commercial |
$4,116.80
|
| Rate for Payer: First Health Commercial |
$4,712.00
|
| Rate for Payer: Humana Commercial |
$4,216.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,067.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,488.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$644.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,537.60
|
| Rate for Payer: PHCS Commercial |
$4,761.60
|
| Rate for Payer: United Healthcare All Payer |
$4,364.80
|
|
|
PET MYOPPERFW/META RDOTRCRW/CT
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404P0016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$310.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$310.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.62
|
| Rate for Payer: Multiplan PHCS |
$186.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$217.00
|
| Rate for Payer: UHCCP Medicaid |
$108.50
|
|
|
PET MYOPPERFW/META TECHNICAL
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404T0016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,770.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,478.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,389.86
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Humana Medicare Advantage |
$1,770.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,124.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
