|
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 |
$1,977.00 |
| 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 |
$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
|
Facility
|
OP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78492
|
| Hospital Charge Code |
404T0007
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,003.70
|
| 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 |
$3,207.50
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$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 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 |
$3,472.00 |
| 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 |
$1,488.00 |
| 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 |
$3,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,315.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.40
|
| Rate for Payer: PHCS Commercial |
$4,761.60
|
| Rate for Payer: United Healthcare All Payer |
$4,364.80
|
|
|
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 |
$1,705.74 |
| 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 |
$1,802.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,523.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,433.00
|
| 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 |
$1,802.22
|
| 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 |
$2,162.66
|
| 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 |
$3,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,315.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.40
|
| 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 |
$217.00 |
| 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
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404T0016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,395.00 |
| 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 |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,045.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,208.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
PET MYOPPERFW/META TECHNICAL
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404T0016
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,599.13 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,802.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,523.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,433.00
|
| 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 |
$1,599.13
|
| Rate for Payer: Humana Medicare Advantage |
$1,802.22
|
| 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 |
$2,162.66
|
| 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 |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,045.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,208.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
PET MYOP (SINGLE)REST OR STRES
|
Facility
|
OP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
404T0006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,003.70
|
| 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 |
$3,207.50
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$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 (SINGLE)REST OR STRES
|
Facility
|
IP
|
$6,415.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
404T0006
|
|
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 (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: 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
|
$6,565.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
40400006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,969.50 |
| 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 |
$5,252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,711.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,529.85
|
| 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
|
$6,565.00
|
|
|
Service Code
|
HCPCS 78491
|
| Hospital Charge Code |
40400006
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$86.63 |
| Max. Negotiated Rate |
$4,595.50 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| 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 |
$1,347.71 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,120.70
|
| 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 |
$3,282.50
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$5,252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,711.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,529.85
|
| Rate for Payer: PHCS Commercial |
$6,302.40
|
| Rate for Payer: United Healthcare All Payer |
$5,777.20
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Facility
|
IP
|
$7,017.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,105.10 |
| 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 |
$5,613.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,104.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,841.73
|
| Rate for Payer: PHCS Commercial |
$6,736.32
|
| Rate for Payer: United Healthcare All Payer |
$6,174.96
|
|
|
PET RHEUMATOID TARGET IMAGING
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400010
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$70.50 |
| 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 |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
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 |
$4,911.90 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,046.34
|
| 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 |
$1,126.35
|
| 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 |
$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
|
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: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$754.72
|
| Rate for Payer: Healthspan PPO |
$1,126.35
|
| 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 |
$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 TARGET IMAGING
|
Facility
|
OP
|
$7,017.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400017
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,347.71 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,473.26
|
| 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 |
$3,508.50
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$5,613.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,104.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,841.73
|
| 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 |
$80.82 |
| Max. Negotiated Rate |
$1,886.79 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem Medicaid |
$80.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| 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 |
$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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
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 |
$2,009.10 |
| 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 |
$5,357.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,826.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,620.93
|
| Rate for Payer: PHCS Commercial |
$6,429.12
|
| Rate for Payer: United Healthcare All Payer |
$5,893.36
|
|
|
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 |
$1,347.71 |
| 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 |
$1,347.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,223.66
|
| 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 |
$3,348.50
|
| 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 |
$1,347.71
|
| 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 |
$1,617.25
|
| 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 |
$5,357.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,826.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,620.93
|
| 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 |
$3.85 |
| 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 |
$10.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.85
|
| 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 |
$3.85 |
| 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 |
$10.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.85
|
| Rate for Payer: PHCS Commercial |
$12.32
|
| Rate for Payer: United Healthcare All Payer |
$11.29
|
|
|
PET RP LOCLZJ TUM SPECT W/CT 1
|
Facility
|
OP
|
$2,713.00
|
|
|
Service Code
|
HCPCS 78830
|
| Hospital Charge Code |
40400011
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$933.00 |
| Max. Negotiated Rate |
$2,604.48 |
| Rate for Payer: Aetna Commercial |
$2,089.01
|
| Rate for Payer: Anthem Medicaid |
$933.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,206.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,116.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,688.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,628.42
|
| Rate for Payer: Cash Price |
$1,356.50
|
| Rate for Payer: Cash Price |
$1,356.50
|
| Rate for Payer: Cigna Commercial |
$2,251.79
|
| Rate for Payer: First Health Commercial |
$2,577.35
|
| Rate for Payer: Humana Commercial |
$2,306.05
|
| Rate for Payer: Humana KY Medicaid |
$933.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,206.24
|
| Rate for Payer: Kentucky WC Medicaid |
$942.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,224.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,002.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$951.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,387.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,034.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,170.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,360.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,871.97
|
| Rate for Payer: PHCS Commercial |
$2,604.48
|
| Rate for Payer: United Healthcare All Payer |
$2,387.44
|
|
