|
PET CT FULLBODY
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404P0009
|
|
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 |
$1,046.34
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$754.72
|
| Rate for Payer: Healthspan PPO |
$1,126.35
|
| 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 |
$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 |
$1,056.80
|
|
|
PET CT FULLBODY
|
Facility
|
IP
|
$7,607.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,282.10 |
| Max. Negotiated Rate |
$7,302.72 |
| Rate for Payer: Aetna Commercial |
$5,857.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,933.46
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cigna Commercial |
$6,313.81
|
| Rate for Payer: First Health Commercial |
$7,226.65
|
| Rate for Payer: Humana Commercial |
$6,465.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,237.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,613.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,282.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,694.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,705.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,085.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,618.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,248.83
|
| Rate for Payer: PHCS Commercial |
$7,302.72
|
| Rate for Payer: United Healthcare All Payer |
$6,694.16
|
|
|
PET CT FULLBODY
|
Facility
|
OP
|
$7,607.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| Max. Negotiated Rate |
$7,302.72 |
| Rate for Payer: Aetna Commercial |
$5,857.39
|
| Rate for Payer: Anthem Medicaid |
$2,616.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,933.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cigna Commercial |
$6,313.81
|
| Rate for Payer: First Health Commercial |
$7,226.65
|
| Rate for Payer: Humana Commercial |
$6,465.95
|
| Rate for Payer: Humana KY Medicaid |
$2,616.05
|
| Rate for Payer: Humana Medicare Advantage |
$1,347.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,642.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,237.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,613.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,617.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,668.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,694.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,705.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,085.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,618.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,248.83
|
| Rate for Payer: PHCS Commercial |
$7,302.72
|
| Rate for Payer: United Healthcare All Payer |
$6,694.16
|
|
|
PET CT FULLBODY(T
|
Facility
|
IP
|
$7,382.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404T0009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,214.60 |
| Max. Negotiated Rate |
$7,086.72 |
| Rate for Payer: Aetna Commercial |
$5,684.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,757.96
|
| Rate for Payer: Cash Price |
$3,691.00
|
| Rate for Payer: Cigna Commercial |
$6,127.06
|
| Rate for Payer: First Health Commercial |
$7,012.90
|
| Rate for Payer: Humana Commercial |
$6,274.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,447.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,905.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,422.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,093.58
|
| Rate for Payer: PHCS Commercial |
$7,086.72
|
| Rate for Payer: United Healthcare All Payer |
$6,496.16
|
|
|
PET CT FULLBODY(T
|
Facility
|
OP
|
$7,382.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404T0009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| Max. Negotiated Rate |
$7,086.72 |
| Rate for Payer: Aetna Commercial |
$5,684.14
|
| Rate for Payer: Anthem Medicaid |
$2,538.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,757.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| Rate for Payer: Cash Price |
$3,691.00
|
| Rate for Payer: Cash Price |
$3,691.00
|
| Rate for Payer: Cigna Commercial |
$6,127.06
|
| Rate for Payer: First Health Commercial |
$7,012.90
|
| Rate for Payer: Humana Commercial |
$6,274.70
|
| Rate for Payer: Humana KY Medicaid |
$2,538.67
|
| Rate for Payer: Humana Medicare Advantage |
$1,347.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,564.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,447.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,617.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,589.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,905.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,422.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,093.58
|
| Rate for Payer: PHCS Commercial |
$7,086.72
|
| Rate for Payer: United Healthcare All Payer |
$6,496.16
|
|
|
PET CT SKULL TO THIGH
|
Facility
|
OP
|
$7,607.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
40400008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| Max. Negotiated Rate |
$7,302.72 |
| Rate for Payer: Aetna Commercial |
$5,857.39
|
| Rate for Payer: Anthem Medicaid |
$2,616.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,933.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cigna Commercial |
$6,313.81
|
| Rate for Payer: First Health Commercial |
$7,226.65
|
| Rate for Payer: Humana Commercial |
$6,465.95
|
| Rate for Payer: Humana KY Medicaid |
$2,616.05
|
| Rate for Payer: Humana Medicare Advantage |
$1,347.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,642.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,237.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,613.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,617.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,668.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,694.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,705.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,085.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,618.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,248.83
|
| Rate for Payer: PHCS Commercial |
$7,302.72
|
| Rate for Payer: United Healthcare All Payer |
$6,694.16
|
|
|
PET CT SKULL TO THIGH
|
Facility
|
IP
|
$7,607.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
40400008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,282.10 |
| Max. Negotiated Rate |
$7,302.72 |
| Rate for Payer: Aetna Commercial |
$5,857.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,933.46
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cigna Commercial |
$6,313.81
|
| Rate for Payer: First Health Commercial |
$7,226.65
|
| Rate for Payer: Humana Commercial |
$6,465.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,237.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,613.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,282.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,694.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,705.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,085.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,618.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,248.83
|
| Rate for Payer: PHCS Commercial |
$7,302.72
|
| Rate for Payer: United Healthcare All Payer |
$6,694.16
|
|
|
PET CT SKULL TO THIGH
|
Professional
|
Both
|
$7,607.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
40400008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$140.77 |
| Max. Negotiated Rate |
$5,324.90 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,044.56
|
| Rate for Payer: Cash Price |
$3,803.50
|
| Rate for Payer: Cash Price |
$3,803.50
|
| 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 |
$4,564.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,324.90
|
| Rate for Payer: UHCCP Medicaid |
$2,662.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,055.01
|
|
|
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: 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
|
$7,382.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
404T0008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| Max. Negotiated Rate |
$7,086.72 |
| Rate for Payer: Aetna Commercial |
$5,684.14
|
| Rate for Payer: Anthem Medicaid |
$2,538.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,757.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| Rate for Payer: Cash Price |
$3,691.00
|
| Rate for Payer: Cash Price |
$3,691.00
|
| Rate for Payer: Cigna Commercial |
$6,127.06
|
| Rate for Payer: First Health Commercial |
$7,012.90
|
| Rate for Payer: Humana Commercial |
$6,274.70
|
| Rate for Payer: Humana KY Medicaid |
$2,538.67
|
| Rate for Payer: Humana Medicare Advantage |
$1,347.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,564.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,447.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,617.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,589.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,905.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,422.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,093.58
|
| Rate for Payer: PHCS Commercial |
$7,086.72
|
| Rate for Payer: United Healthcare All Payer |
$6,496.16
|
|
|
PET CT SKULL TO THIGH(T
|
Facility
|
IP
|
$7,382.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
404T0008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,214.60 |
| Max. Negotiated Rate |
$7,086.72 |
| Rate for Payer: Aetna Commercial |
$5,684.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,757.96
|
| Rate for Payer: Cash Price |
$3,691.00
|
| Rate for Payer: Cigna Commercial |
$6,127.06
|
| Rate for Payer: First Health Commercial |
$7,012.90
|
| Rate for Payer: Humana Commercial |
$6,274.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,447.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,905.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,422.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,093.58
|
| Rate for Payer: PHCS Commercial |
$7,086.72
|
| Rate for Payer: United Healthcare All Payer |
$6,496.16
|
|
|
PETIMG FDG-18 (>=45 MCI)
|
Facility
|
OP
|
$1,046.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
34000061
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$313.80 |
| Max. Negotiated Rate |
$1,004.16 |
| Rate for Payer: Aetna Commercial |
$805.42
|
| Rate for Payer: Anthem Medicaid |
$359.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.88
|
| Rate for Payer: Cash Price |
$523.00
|
| Rate for Payer: Cigna Commercial |
$868.18
|
| Rate for Payer: First Health Commercial |
$993.70
|
| Rate for Payer: Humana Commercial |
$889.10
|
| Rate for Payer: Humana KY Medicaid |
$359.72
|
| Rate for Payer: Kentucky WC Medicaid |
$363.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$857.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$366.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$920.48
|
| Rate for Payer: Ohio Health Group HMO |
$784.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$910.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.74
|
| Rate for Payer: PHCS Commercial |
$1,004.16
|
| Rate for Payer: United Healthcare All Payer |
$920.48
|
|
|
PETIMG FDG-18 (>=45 MCI)
|
Facility
|
IP
|
$1,046.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
34000061
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$313.80 |
| Max. Negotiated Rate |
$1,004.16 |
| Rate for Payer: Aetna Commercial |
$805.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.88
|
| Rate for Payer: Cash Price |
$523.00
|
| Rate for Payer: Cigna Commercial |
$868.18
|
| Rate for Payer: First Health Commercial |
$993.70
|
| Rate for Payer: Humana Commercial |
$889.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$857.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$920.48
|
| Rate for Payer: Ohio Health Group HMO |
$784.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$910.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.74
|
| Rate for Payer: PHCS Commercial |
$1,004.16
|
| Rate for Payer: United Healthcare All Payer |
$920.48
|
|
|
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 |
$747.60 |
| 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 |
$1,993.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,168.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,719.48
|
| 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
|
OP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 78429
|
| Hospital Charge Code |
40400001
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$857.00 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,943.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$1,993.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,168.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,719.48
|
| Rate for Payer: PHCS Commercial |
$2,392.32
|
| Rate for Payer: United Healthcare All Payer |
$2,192.96
|
|
|
PET MYOCRDRST/STRSPERFSINGW/CT
|
Facility
|
IP
|
$2,726.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
40400002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$817.80 |
| Max. Negotiated Rate |
$2,616.96 |
| Rate for Payer: Aetna Commercial |
$2,099.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,126.28
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cigna Commercial |
$2,262.58
|
| Rate for Payer: First Health Commercial |
$2,589.70
|
| Rate for Payer: Humana Commercial |
$2,317.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,235.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$817.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,044.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,880.94
|
| Rate for Payer: PHCS Commercial |
$2,616.96
|
| Rate for Payer: United Healthcare All Payer |
$2,398.88
|
|
|
PET MYOCRDRST/STRSPERFSINGW/CT
|
Facility
|
OP
|
$2,726.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
40400002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$937.47 |
| Max. Negotiated Rate |
$2,616.96 |
| Rate for Payer: Aetna Commercial |
$2,099.02
|
| Rate for Payer: Anthem Medicaid |
$937.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,126.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cigna Commercial |
$2,262.58
|
| Rate for Payer: First Health Commercial |
$2,589.70
|
| Rate for Payer: Humana Commercial |
$2,317.10
|
| Rate for Payer: Humana KY Medicaid |
$937.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,347.71
|
| Rate for Payer: Kentucky WC Medicaid |
$947.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,235.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,617.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$956.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,044.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,880.94
|
| Rate for Payer: PHCS Commercial |
$2,616.96
|
| Rate for Payer: United Healthcare All Payer |
$2,398.88
|
|
|
PET MYOCRDRST/STRSPERFSINGW/CT
|
Professional
|
Both
|
$2,726.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
40400002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$1,908.20 |
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.43
|
| Rate for Payer: Multiplan PHCS |
$1,635.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,908.20
|
| Rate for Payer: UHCCP Medicaid |
$954.10
|
|
|
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 |
$196.00 |
| 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
|
$2,446.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
404T0002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$841.18 |
| Max. Negotiated Rate |
$2,348.16 |
| Rate for Payer: Aetna Commercial |
$1,883.42
|
| Rate for Payer: Anthem Medicaid |
$841.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,907.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| Rate for Payer: Cash Price |
$1,223.00
|
| Rate for Payer: Cash Price |
$1,223.00
|
| Rate for Payer: Cigna Commercial |
$2,030.18
|
| Rate for Payer: First Health Commercial |
$2,323.70
|
| Rate for Payer: Humana Commercial |
$2,079.10
|
| Rate for Payer: Humana KY Medicaid |
$841.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,347.71
|
| Rate for Payer: Kentucky WC Medicaid |
$849.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,005.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,805.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,617.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$858.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,152.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,834.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,956.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,128.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.74
|
| Rate for Payer: PHCS Commercial |
$2,348.16
|
| Rate for Payer: United Healthcare All Payer |
$2,152.48
|
|
|
PET MYOCRDRST/STRSPERFSW/CT (T
|
Facility
|
IP
|
$2,446.00
|
|
|
Service Code
|
HCPCS 78430
|
| Hospital Charge Code |
404T0002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$733.80 |
| Max. Negotiated Rate |
$2,348.16 |
| Rate for Payer: Aetna Commercial |
$1,883.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,907.88
|
| Rate for Payer: Cash Price |
$1,223.00
|
| Rate for Payer: Cigna Commercial |
$2,030.18
|
| Rate for Payer: First Health Commercial |
$2,323.70
|
| Rate for Payer: Humana Commercial |
$2,079.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,005.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,805.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$733.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,152.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,834.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,956.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,128.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.74
|
| Rate for Payer: PHCS Commercial |
$2,348.16
|
| Rate for Payer: United Healthcare All Payer |
$2,152.48
|
|
|
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 |
$1,347.71 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,140.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,886.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,819.41
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$5,272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,733.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,547.10
|
| 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
|
$6,590.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
40400007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$109.62 |
| Max. Negotiated Rate |
$4,613.00 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| 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 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 |
$1,924.50 |
| 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 |
$5,132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,581.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,426.35
|
| 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
|
$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: 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
|
|
