|
DUP-SCAN HEMO COMPL BI STD
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 93985
|
| Hospital Charge Code |
92100017
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
DUP-SCAN HEMO COMPL BI STD
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 93985
|
| Hospital Charge Code |
92100017
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$55.60 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Anthem Medicaid |
$197.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Humana Medicaid |
$197.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.74
|
| Rate for Payer: Molina Healthcare Passport |
$197.78
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.76
|
|
|
DUP-SCAN HEMO COMPL BI STD
|
Facility
|
IP
|
$560.00
|
|
|
Service Code
|
HCPCS 93985
|
| Hospital Charge Code |
921T0017
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$537.60 |
| Rate for Payer: Aetna Commercial |
$431.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.80
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$464.80
|
| Rate for Payer: First Health Commercial |
$532.00
|
| Rate for Payer: Humana Commercial |
$476.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$459.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$413.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.80
|
| Rate for Payer: Ohio Health Group HMO |
$420.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.60
|
| Rate for Payer: PHCS Commercial |
$537.60
|
| Rate for Payer: United Healthcare All Payer |
$492.80
|
|
|
DUP-SCAN HEMO COMPL UNI
|
Facility
|
IP
|
$680.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
92100020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$652.80 |
| Rate for Payer: Aetna Commercial |
$523.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$530.40
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$646.00
|
| Rate for Payer: Humana Commercial |
$578.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$204.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$598.40
|
| Rate for Payer: Ohio Health Group HMO |
$510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.80
|
| Rate for Payer: PHCS Commercial |
$652.80
|
| Rate for Payer: United Healthcare All Payer |
$598.40
|
|
|
DUP-SCAN HEMO COMPL UNI
|
Professional
|
Both
|
$680.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
92100020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$35.98 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Anthem Medicaid |
$114.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$680.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Humana Medicaid |
$114.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$117.15
|
| Rate for Payer: Molina Healthcare Passport |
$114.85
|
| Rate for Payer: Multiplan PHCS |
$408.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$476.00
|
| Rate for Payer: UHCCP Medicaid |
$238.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$116.00
|
|
|
DUP-SCAN HEMO COMPL UNI
|
Facility
|
OP
|
$680.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
92100020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$652.80 |
| Rate for Payer: Aetna Commercial |
$523.60
|
| Rate for Payer: Anthem Medicaid |
$233.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$530.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$646.00
|
| Rate for Payer: Humana Commercial |
$578.00
|
| Rate for Payer: Humana KY Medicaid |
$233.85
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$236.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$238.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$598.40
|
| Rate for Payer: Ohio Health Group HMO |
$510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.80
|
| Rate for Payer: PHCS Commercial |
$652.80
|
| Rate for Payer: United Healthcare All Payer |
$598.40
|
|
|
DUP-SCAN HEMO COMPL UNI(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
921P0020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$35.98 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Anthem Medicaid |
$114.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Humana Medicaid |
$114.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$117.15
|
| Rate for Payer: Molina Healthcare Passport |
$114.85
|
| 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 |
$116.00
|
|
|
DUP-SCAN HEMO COMPL UNI STD
|
Facility
|
OP
|
$455.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
92100018
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$59.15 |
| Max. Negotiated Rate |
$436.80 |
| Rate for Payer: Aetna Commercial |
$350.35
|
| Rate for Payer: Anthem Medicaid |
$156.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cigna Commercial |
$377.65
|
| Rate for Payer: First Health Commercial |
$432.25
|
| Rate for Payer: Humana Commercial |
$386.75
|
| Rate for Payer: Humana KY Medicaid |
$156.47
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$158.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$373.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$335.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$159.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$400.40
|
| Rate for Payer: Ohio Health Group HMO |
$341.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.05
|
| Rate for Payer: PHCS Commercial |
$436.80
|
| Rate for Payer: United Healthcare All Payer |
$400.40
|
|
|
DUP-SCAN HEMO COMPL UNI STD
|
Facility
|
IP
|
$455.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
92100018
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$59.15 |
| Max. Negotiated Rate |
$436.80 |
| Rate for Payer: Aetna Commercial |
$350.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.90
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cigna Commercial |
$377.65
|
| Rate for Payer: First Health Commercial |
$432.25
|
| Rate for Payer: Humana Commercial |
$386.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$373.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$335.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$400.40
|
| Rate for Payer: Ohio Health Group HMO |
$341.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.05
|
| Rate for Payer: PHCS Commercial |
$436.80
|
| Rate for Payer: United Healthcare All Payer |
$400.40
|
|
|
DUP-SCAN HEMO COMPL UNI(T
|
Facility
|
OP
|
$455.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
921T0020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$59.15 |
| Max. Negotiated Rate |
$436.80 |
| Rate for Payer: Aetna Commercial |
$350.35
|
| Rate for Payer: Anthem Medicaid |
$156.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cigna Commercial |
$377.65
|
| Rate for Payer: First Health Commercial |
$432.25
|
| Rate for Payer: Humana Commercial |
$386.75
|
| Rate for Payer: Humana KY Medicaid |
$156.47
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$158.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$373.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$335.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$159.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$400.40
|
| Rate for Payer: Ohio Health Group HMO |
$341.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.05
|
| Rate for Payer: PHCS Commercial |
$436.80
|
| Rate for Payer: United Healthcare All Payer |
$400.40
|
|
|
DUP-SCAN HEMO COMPL UNI(T
|
Facility
|
IP
|
$455.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
921T0020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$59.15 |
| Max. Negotiated Rate |
$436.80 |
| Rate for Payer: Aetna Commercial |
$350.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.90
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cigna Commercial |
$377.65
|
| Rate for Payer: First Health Commercial |
$432.25
|
| Rate for Payer: Humana Commercial |
$386.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$373.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$335.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$400.40
|
| Rate for Payer: Ohio Health Group HMO |
$341.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.05
|
| Rate for Payer: PHCS Commercial |
$436.80
|
| Rate for Payer: United Healthcare All Payer |
$400.40
|
|
|
DUP SCAN OF AORTA - COMPLETE
|
Professional
|
Both
|
$1,401.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
32000301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$44.66 |
| Max. Negotiated Rate |
$1,401.00 |
| Rate for Payer: Aetna Commercial |
$285.97
|
| Rate for Payer: Anthem Medicaid |
$139.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,401.00
|
| Rate for Payer: Cash Price |
$700.50
|
| Rate for Payer: Cash Price |
$700.50
|
| Rate for Payer: Cigna Commercial |
$283.54
|
| Rate for Payer: Healthspan PPO |
$305.47
|
| Rate for Payer: Humana Medicaid |
$139.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$142.18
|
| Rate for Payer: Molina Healthcare Passport |
$139.39
|
| Rate for Payer: Multiplan PHCS |
$840.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$980.70
|
| Rate for Payer: UHCCP Medicaid |
$490.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.78
|
|
|
DUP SCAN OF AORTA - COMPLETE
|
Facility
|
IP
|
$1,401.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
32000301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$182.13 |
| Max. Negotiated Rate |
$1,344.96 |
| Rate for Payer: Aetna Commercial |
$1,078.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.78
|
| Rate for Payer: Cash Price |
$700.50
|
| Rate for Payer: Cigna Commercial |
$1,162.83
|
| Rate for Payer: First Health Commercial |
$1,330.95
|
| Rate for Payer: Humana Commercial |
$1,190.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$182.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$434.31
|
| Rate for Payer: PHCS Commercial |
$1,344.96
|
| Rate for Payer: United Healthcare All Payer |
$1,232.88
|
|
|
DUP SCAN OF AORTA - COMPLETE
|
Facility
|
OP
|
$1,401.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
32000301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$182.13 |
| Max. Negotiated Rate |
$1,344.96 |
| Rate for Payer: Cigna Commercial |
$1,162.83
|
| Rate for Payer: Aetna Commercial |
$1,078.77
|
| Rate for Payer: Anthem Medicaid |
$481.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$700.50
|
| Rate for Payer: Cash Price |
$700.50
|
| Rate for Payer: First Health Commercial |
$1,330.95
|
| Rate for Payer: Humana Commercial |
$1,190.85
|
| Rate for Payer: Humana KY Medicaid |
$481.80
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$486.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$491.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$182.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$434.31
|
| Rate for Payer: PHCS Commercial |
$1,344.96
|
| Rate for Payer: United Healthcare All Payer |
$1,232.88
|
|
|
DUP SCAN OF AORTA - COMPLETE(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
320P0301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$44.66 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$285.97
|
| Rate for Payer: Anthem Medicaid |
$139.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$283.54
|
| Rate for Payer: Healthspan PPO |
$305.47
|
| Rate for Payer: Humana Medicaid |
$139.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$142.18
|
| Rate for Payer: Molina Healthcare Passport |
$139.39
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.78
|
|
|
DUP SCAN OF AORTA - COMPLETE(T
|
Facility
|
IP
|
$1,051.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
320T0301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$136.63 |
| Max. Negotiated Rate |
$1,008.96 |
| Rate for Payer: Aetna Commercial |
$809.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$819.78
|
| Rate for Payer: Cash Price |
$525.50
|
| Rate for Payer: Cigna Commercial |
$872.33
|
| Rate for Payer: First Health Commercial |
$998.45
|
| Rate for Payer: Humana Commercial |
$893.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$861.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$775.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$315.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$924.88
|
| Rate for Payer: Ohio Health Group HMO |
$788.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$210.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$325.81
|
| Rate for Payer: PHCS Commercial |
$1,008.96
|
| Rate for Payer: United Healthcare All Payer |
$924.88
|
|
|
DUP SCAN OF AORTA - COMPLETE(T
|
Facility
|
OP
|
$1,051.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
320T0301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$136.63 |
| Max. Negotiated Rate |
$1,008.96 |
| Rate for Payer: Aetna Commercial |
$809.27
|
| Rate for Payer: Anthem Medicaid |
$361.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$819.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$525.50
|
| Rate for Payer: Cash Price |
$525.50
|
| Rate for Payer: Cigna Commercial |
$872.33
|
| Rate for Payer: First Health Commercial |
$998.45
|
| Rate for Payer: Humana Commercial |
$893.35
|
| Rate for Payer: Humana KY Medicaid |
$361.44
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$365.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$861.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$775.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$368.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$924.88
|
| Rate for Payer: Ohio Health Group HMO |
$788.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$210.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$325.81
|
| Rate for Payer: PHCS Commercial |
$1,008.96
|
| Rate for Payer: United Healthcare All Payer |
$924.88
|
|
|
DUP SCAN OF AORTA - LIMITED
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
92100015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$118.30 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$273.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$182.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$282.10
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
|
DUP SCAN OF AORTA - LIMITED
|
Professional
|
Both
|
$910.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
92100015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$29.54 |
| Max. Negotiated Rate |
$910.00 |
| Rate for Payer: Aetna Commercial |
$183.42
|
| Rate for Payer: Anthem Medicaid |
$92.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$910.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: Healthspan PPO |
$195.93
|
| Rate for Payer: Humana Medicaid |
$92.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.72
|
| Rate for Payer: Molina Healthcare Passport |
$92.86
|
| Rate for Payer: Multiplan PHCS |
$546.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$637.00
|
| Rate for Payer: UHCCP Medicaid |
$318.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.79
|
|
|
DUP SCAN OF AORTA - LIMITED
|
Facility
|
OP
|
$910.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
92100015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem Medicaid |
$312.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Humana KY Medicaid |
$312.95
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$316.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$319.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$182.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$282.10
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
|
DUP SCAN OF AORTA - LIMITED(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
921P0015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$29.54 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$183.42
|
| Rate for Payer: Anthem Medicaid |
$92.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: Healthspan PPO |
$195.93
|
| Rate for Payer: Humana Medicaid |
$92.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.72
|
| Rate for Payer: Molina Healthcare Passport |
$92.86
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.79
|
|
|
DUP SCAN OF AORTA - LIMITED(T
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
921T0015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
DUP SCAN OF AORTA - LIMITED(T
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
921T0015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92000006
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$37.83 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Aetna Commercial |
$224.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.98
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$241.53
|
| Rate for Payer: First Health Commercial |
$276.45
|
| Rate for Payer: Humana Commercial |
$247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.08
|
| Rate for Payer: Ohio Health Group HMO |
$218.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.21
|
| Rate for Payer: PHCS Commercial |
$279.36
|
| Rate for Payer: United Healthcare All Payer |
$256.08
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
921T0003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$37.83 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Aetna Commercial |
$224.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.98
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$241.53
|
| Rate for Payer: First Health Commercial |
$276.45
|
| Rate for Payer: Humana Commercial |
$247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.08
|
| Rate for Payer: Ohio Health Group HMO |
$218.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.21
|
| Rate for Payer: PHCS Commercial |
$279.36
|
| Rate for Payer: United Healthcare All Payer |
$256.08
|
|
