|
PET MYOPPERFW/META TECHNICAL
|
Facility
|
IP
|
$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 POS/PPO/Traditional |
$3,627.00
|
| 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: 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 |
$1,395.00
|
| 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
|
|
|
PET MYOP (SINGLE)REST OR STRES
|
Professional
|
Both
|
$6,565.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
40400006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$86.63 |
| Max. Negotiated Rate |
$6,565.00 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,565.00
|
| Rate for Payer: Cash Price |
$3,282.50
|
| Rate for Payer: Cash Price |
$3,282.50
|
| Rate for Payer: Cigna Commercial |
$392.83
|
| Rate for Payer: Healthspan PPO |
$1,233.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.63
|
| Rate for Payer: Multiplan PHCS |
$3,939.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,595.50
|
| Rate for Payer: UHCCP Medicaid |
$2,297.75
|
|
|
PET MYOP (SINGLE)REST OR STRES
|
Facility
|
OP
|
$6,565.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
40400006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$853.45 |
| Max. Negotiated Rate |
$6,302.40 |
| Rate for Payer: Aetna Commercial |
$5,055.05
|
| Rate for Payer: Anthem Medicaid |
$2,257.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,120.70
|
| 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 |
$3,282.50
|
| Rate for Payer: Cash Price |
$3,282.50
|
| Rate for Payer: Cigna Commercial |
$5,448.95
|
| Rate for Payer: First Health Commercial |
$6,236.75
|
| Rate for Payer: Humana Commercial |
$5,580.25
|
| Rate for Payer: Humana KY Medicaid |
$2,257.70
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,280.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,383.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,844.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,303.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,777.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,923.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,313.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,035.15
|
| Rate for Payer: PHCS Commercial |
$6,302.40
|
| Rate for Payer: United Healthcare All Payer |
$5,777.20
|
|
|
PET MYOP (SINGLE)REST OR STRES
|
Facility
|
IP
|
$6,565.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
40400006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$853.45 |
| Max. Negotiated Rate |
$6,302.40 |
| Rate for Payer: Aetna Commercial |
$5,055.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,120.70
|
| Rate for Payer: Cash Price |
$3,282.50
|
| Rate for Payer: Cigna Commercial |
$5,448.95
|
| Rate for Payer: First Health Commercial |
$6,236.75
|
| Rate for Payer: Humana Commercial |
$5,580.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,383.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,844.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,969.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,777.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,923.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,313.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,035.15
|
| Rate for Payer: PHCS Commercial |
$6,302.40
|
| Rate for Payer: United Healthcare All Payer |
$5,777.20
|
|
|
PET MYOP (SINGLE)REST OR STRES
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
404P0006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$2,081.06 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$392.83
|
| Rate for Payer: Healthspan PPO |
$1,233.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.63
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
PET MYOP (SINGLE)REST OR STRES
|
Facility
|
IP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
404T0006
|
|
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 (SINGLE)REST OR STRES
|
Facility
|
OP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
404T0006
|
|
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 RHEUMATOID TARGET IMAGING
|
Facility
|
IP
|
$7,017.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$912.21 |
| Max. Negotiated Rate |
$6,736.32 |
| Rate for Payer: Aetna Commercial |
$5,403.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,473.26
|
| Rate for Payer: Cash Price |
$3,508.50
|
| Rate for Payer: Cigna Commercial |
$5,824.11
|
| Rate for Payer: First Health Commercial |
$6,666.15
|
| Rate for Payer: Humana Commercial |
$5,964.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,753.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,178.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,105.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,174.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,262.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,403.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$912.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,175.27
|
| Rate for Payer: PHCS Commercial |
$6,736.32
|
| Rate for Payer: United Healthcare All Payer |
$6,174.96
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400010
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$1,894.02 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem Medicaid |
$80.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| 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 |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Humana KY Medicaid |
$80.82
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$81.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Facility
|
OP
|
$7,017.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$912.21 |
| Max. Negotiated Rate |
$6,736.32 |
| Rate for Payer: Aetna Commercial |
$5,403.09
|
| Rate for Payer: Anthem Medicaid |
$2,413.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,473.26
|
| 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 |
$3,508.50
|
| Rate for Payer: Cash Price |
$3,508.50
|
| Rate for Payer: Cigna Commercial |
$5,824.11
|
| Rate for Payer: First Health Commercial |
$6,666.15
|
| Rate for Payer: Humana Commercial |
$5,964.45
|
| Rate for Payer: Humana KY Medicaid |
$2,413.15
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,753.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,178.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,461.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,174.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,262.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,403.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$912.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,175.27
|
| Rate for Payer: PHCS Commercial |
$6,736.32
|
| Rate for Payer: United Healthcare All Payer |
$6,174.96
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Professional
|
Both
|
$7,017.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$143.09 |
| Max. Negotiated Rate |
$7,017.00 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,046.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,017.00
|
| Rate for Payer: Cash Price |
$3,508.50
|
| Rate for Payer: Cash Price |
$3,508.50
|
| Rate for Payer: Cigna Commercial |
$754.72
|
| Rate for Payer: Healthspan PPO |
$1,126.34
|
| Rate for Payer: Humana Medicaid |
$1,046.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$143.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,067.27
|
| Rate for Payer: Molina Healthcare Passport |
$1,046.34
|
| Rate for Payer: Multiplan PHCS |
$4,210.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,911.90
|
| Rate for Payer: UHCCP Medicaid |
$2,455.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,056.80
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400010
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Professional
|
Both
|
$320.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404P0017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$112.00 |
| Max. Negotiated Rate |
$2,081.06 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,046.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$320.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$754.72
|
| Rate for Payer: Healthspan PPO |
$1,126.34
|
| Rate for Payer: Humana Medicaid |
$1,046.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$143.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,067.27
|
| Rate for Payer: Molina Healthcare Passport |
$1,046.34
|
| Rate for Payer: Multiplan PHCS |
$192.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.00
|
| Rate for Payer: UHCCP Medicaid |
$112.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,056.80
|
|
|
PET RHEUMATOID TRGT IMAGING(T
|
Facility
|
OP
|
$6,697.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404T0017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$870.61 |
| Max. Negotiated Rate |
$6,429.12 |
| Rate for Payer: Aetna Commercial |
$5,156.69
|
| Rate for Payer: Anthem Medicaid |
$2,303.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,223.66
|
| 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 |
$3,348.50
|
| Rate for Payer: Cash Price |
$3,348.50
|
| Rate for Payer: Cigna Commercial |
$5,558.51
|
| Rate for Payer: First Health Commercial |
$6,362.15
|
| Rate for Payer: Humana Commercial |
$5,692.45
|
| Rate for Payer: Humana KY Medicaid |
$2,303.10
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,326.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,491.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,942.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,349.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,893.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,022.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,339.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,076.07
|
| Rate for Payer: PHCS Commercial |
$6,429.12
|
| Rate for Payer: United Healthcare All Payer |
$5,893.36
|
|
|
PET RHEUMATOID TRGT IMAGING(T
|
Facility
|
IP
|
$6,697.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404T0017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$870.61 |
| Max. Negotiated Rate |
$6,429.12 |
| Rate for Payer: Aetna Commercial |
$5,156.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,223.66
|
| Rate for Payer: Cash Price |
$3,348.50
|
| Rate for Payer: Cigna Commercial |
$5,558.51
|
| Rate for Payer: First Health Commercial |
$6,362.15
|
| Rate for Payer: Humana Commercial |
$5,692.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,491.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,942.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,009.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,893.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,022.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,339.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,076.07
|
| Rate for Payer: PHCS Commercial |
$6,429.12
|
| Rate for Payer: United Healthcare All Payer |
$5,893.36
|
|
|
PETROLATUM,WHITE 454 GM OINT
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 536114398
|
| Hospital Charge Code |
25003973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$12.32 |
| Rate for Payer: Aetna Commercial |
$9.88
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.01
|
| Rate for Payer: Cash Price |
$6.42
|
| Rate for Payer: Cigna Commercial |
$10.65
|
| Rate for Payer: First Health Commercial |
$12.19
|
| Rate for Payer: Humana Commercial |
$10.91
|
| Rate for Payer: Humana KY Medicaid |
$4.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.29
|
| Rate for Payer: Ohio Health Group HMO |
$9.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.98
|
| Rate for Payer: PHCS Commercial |
$12.32
|
| Rate for Payer: United Healthcare All Payer |
$11.29
|
|
|
PETROLATUM,WHITE 454 GM OINT
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 536114398
|
| Hospital Charge Code |
25003973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$12.32 |
| Rate for Payer: Aetna Commercial |
$9.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.01
|
| Rate for Payer: Cash Price |
$6.42
|
| Rate for Payer: Cigna Commercial |
$10.65
|
| Rate for Payer: First Health Commercial |
$12.19
|
| Rate for Payer: Humana Commercial |
$10.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.29
|
| Rate for Payer: Ohio Health Group HMO |
$9.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.98
|
| Rate for Payer: PHCS Commercial |
$12.32
|
| Rate for Payer: United Healthcare All Payer |
$11.29
|
|
|
PET RP LOCLZJ TUM SPECT W/CT 1
|
Professional
|
Both
|
$2,564.00
|
|
|
Service Code
|
HCPCS 78830
|
| Hospital Charge Code |
40400011
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$81.94 |
| Max. Negotiated Rate |
$2,564.00 |
| Rate for Payer: Anthem Medicaid |
$369.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,564.00
|
| Rate for Payer: Cash Price |
$1,282.00
|
| Rate for Payer: Cash Price |
$1,282.00
|
| Rate for Payer: Humana Medicaid |
$369.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$81.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$377.11
|
| Rate for Payer: Molina Healthcare Passport |
$369.72
|
| Rate for Payer: Multiplan PHCS |
$1,538.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,794.80
|
| Rate for Payer: UHCCP Medicaid |
$897.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$373.42
|
|
|
PET RP LOCLZJ TUM SPECT W/CT 1
|
Facility
|
IP
|
$2,564.00
|
|
|
Service Code
|
HCPCS 78830
|
| Hospital Charge Code |
40400011
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$333.32 |
| Max. Negotiated Rate |
$2,461.44 |
| Rate for Payer: Aetna Commercial |
$1,974.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,999.92
|
| Rate for Payer: Cash Price |
$1,282.00
|
| Rate for Payer: Cigna Commercial |
$2,128.12
|
| Rate for Payer: First Health Commercial |
$2,435.80
|
| Rate for Payer: Humana Commercial |
$2,179.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,102.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,892.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$769.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,256.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,923.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$333.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$794.84
|
| Rate for Payer: PHCS Commercial |
$2,461.44
|
| Rate for Payer: United Healthcare All Payer |
$2,256.32
|
|
|
PET RP LOCLZJ TUM SPECT W/CT 1
|
Facility
|
OP
|
$2,564.00
|
|
|
Service Code
|
HCPCS 78830
|
| Hospital Charge Code |
40400011
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$333.32 |
| Max. Negotiated Rate |
$2,461.44 |
| Rate for Payer: Aetna Commercial |
$1,974.28
|
| Rate for Payer: Anthem Medicaid |
$881.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,227.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,999.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,719.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,657.69
|
| Rate for Payer: Cash Price |
$1,282.00
|
| Rate for Payer: Cash Price |
$1,282.00
|
| Rate for Payer: Cigna Commercial |
$2,128.12
|
| Rate for Payer: First Health Commercial |
$2,435.80
|
| Rate for Payer: Humana Commercial |
$2,179.40
|
| Rate for Payer: Humana KY Medicaid |
$881.76
|
| Rate for Payer: Humana Medicare Advantage |
$1,227.92
|
| Rate for Payer: Kentucky WC Medicaid |
$890.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,102.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,892.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$899.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,256.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,923.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$333.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$794.84
|
| Rate for Payer: PHCS Commercial |
$2,461.44
|
| Rate for Payer: United Healthcare All Payer |
$2,256.32
|
|
|
PET RP LOCLZJ TUM SPECT W/CT 2
|
Facility
|
OP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78832
|
| Hospital Charge Code |
40400013
|
|
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 RP LOCLZJ TUM SPECT W/CT 2
|
Facility
|
IP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78832
|
| Hospital Charge Code |
40400013
|
|
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 RP QUAN MEAS SINGLE AREA
|
Facility
|
IP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78835
|
| Hospital Charge Code |
40400014
|
|
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 RP QUAN MEAS SINGLE AREA
|
Facility
|
OP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78835
|
| Hospital Charge Code |
40400014
|
|
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 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: Humana KY Medicaid |
$857.00
|
| 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 |
$747.60
|
| 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
|
|
|
PFC DIST. AUG. 4*4MM RT
|
Facility
|
IP
|
$8,567.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,113.78 |
| Max. Negotiated Rate |
$8,224.85 |
| Rate for Payer: Aetna Commercial |
$6,597.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,682.69
|
| Rate for Payer: Cash Price |
$4,283.77
|
| Rate for Payer: Cigna Commercial |
$7,111.07
|
| Rate for Payer: First Health Commercial |
$8,139.17
|
| Rate for Payer: Humana Commercial |
$7,282.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,025.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,322.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,570.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,539.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,425.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,713.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,113.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,655.94
|
| Rate for Payer: PHCS Commercial |
$8,224.85
|
| Rate for Payer: United Healthcare All Payer |
$7,539.44
|
|
