|
DUP-SCAN HEMO COMPL UNI(T
|
Facility
|
IP
|
$471.00
|
|
|
Service Code
|
HCPCS 93986
|
| Hospital Charge Code |
921T0020
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$141.30 |
| Max. Negotiated Rate |
$452.16 |
| Rate for Payer: Aetna Commercial |
$362.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$367.38
|
| Rate for Payer: Cash Price |
$235.50
|
| Rate for Payer: Cigna Commercial |
$390.93
|
| Rate for Payer: First Health Commercial |
$447.45
|
| Rate for Payer: Humana Commercial |
$400.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$386.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$347.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$414.48
|
| Rate for Payer: Ohio Health Group HMO |
$353.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$409.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$324.99
|
| Rate for Payer: PHCS Commercial |
$452.16
|
| Rate for Payer: United Healthcare All Payer |
$414.48
|
|
|
DUP SCAN OF AORTA - COMPLETE
|
Facility
|
IP
|
$1,438.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
32000301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$431.40 |
| Max. Negotiated Rate |
$1,380.48 |
| Rate for Payer: Aetna Commercial |
$1,107.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,121.64
|
| Rate for Payer: Cash Price |
$719.00
|
| Rate for Payer: Cigna Commercial |
$1,193.54
|
| Rate for Payer: First Health Commercial |
$1,366.10
|
| Rate for Payer: Humana Commercial |
$1,222.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,179.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$431.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,265.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,078.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,150.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,251.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.22
|
| Rate for Payer: PHCS Commercial |
$1,380.48
|
| Rate for Payer: United Healthcare All Payer |
$1,265.44
|
|
|
DUP SCAN OF AORTA - COMPLETE
|
Facility
|
OP
|
$1,438.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
32000301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$1,380.48 |
| Rate for Payer: Aetna Commercial |
$1,107.26
|
| Rate for Payer: Anthem Medicaid |
$494.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,121.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$719.00
|
| Rate for Payer: Cash Price |
$719.00
|
| Rate for Payer: Cigna Commercial |
$1,193.54
|
| Rate for Payer: First Health Commercial |
$1,366.10
|
| Rate for Payer: Humana Commercial |
$1,222.30
|
| Rate for Payer: Humana KY Medicaid |
$494.53
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$499.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,179.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$504.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,265.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,078.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,150.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,251.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.22
|
| Rate for Payer: PHCS Commercial |
$1,380.48
|
| Rate for Payer: United Healthcare All Payer |
$1,265.44
|
|
|
DUP SCAN OF AORTA - COMPLETE
|
Professional
|
Both
|
$1,438.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
32000301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$44.66 |
| Max. Negotiated Rate |
$862.80 |
| Rate for Payer: Aetna Commercial |
$285.97
|
| Rate for Payer: Ambetter Exchange |
$161.43
|
| Rate for Payer: Anthem Medicaid |
$139.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$193.72
|
| Rate for Payer: Cash Price |
$719.00
|
| Rate for Payer: Cash Price |
$719.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$161.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$142.18
|
| Rate for Payer: Molina Healthcare Passport |
$139.39
|
| Rate for Payer: Multiplan PHCS |
$862.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$209.86
|
| Rate for Payer: UHCCP Medicaid |
$503.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.43
|
|
|
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 |
$305.47 |
| Rate for Payer: Aetna Commercial |
$285.97
|
| Rate for Payer: Ambetter Exchange |
$161.43
|
| Rate for Payer: Anthem Medicaid |
$139.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$193.72
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$161.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.43
|
| 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 |
$209.86
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.43
|
|
|
DUP SCAN OF AORTA - COMPLETE(T
|
Facility
|
OP
|
$1,088.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
320T0301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$1,044.48 |
| Rate for Payer: Aetna Commercial |
$837.76
|
| Rate for Payer: Anthem Medicaid |
$374.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$848.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$903.04
|
| Rate for Payer: First Health Commercial |
$1,033.60
|
| Rate for Payer: Humana Commercial |
$924.80
|
| Rate for Payer: Humana KY Medicaid |
$374.16
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$377.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$802.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$381.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$957.44
|
| Rate for Payer: Ohio Health Group HMO |
$816.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.72
|
| Rate for Payer: PHCS Commercial |
$1,044.48
|
| Rate for Payer: United Healthcare All Payer |
$957.44
|
|
|
DUP SCAN OF AORTA - COMPLETE(T
|
Facility
|
IP
|
$1,088.00
|
|
|
Service Code
|
HCPCS 93978
|
| Hospital Charge Code |
320T0301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$1,044.48 |
| Rate for Payer: Aetna Commercial |
$837.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$848.64
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$903.04
|
| Rate for Payer: First Health Commercial |
$1,033.60
|
| Rate for Payer: Humana Commercial |
$924.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$802.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$326.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$957.44
|
| Rate for Payer: Ohio Health Group HMO |
$816.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.72
|
| Rate for Payer: PHCS Commercial |
$1,044.48
|
| Rate for Payer: United Healthcare All Payer |
$957.44
|
|
|
DUP SCAN OF AORTA - LIMITED
|
Professional
|
Both
|
$931.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
92100015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$29.54 |
| Max. Negotiated Rate |
$558.60 |
| Rate for Payer: Aetna Commercial |
$183.42
|
| Rate for Payer: Ambetter Exchange |
$104.56
|
| Rate for Payer: Anthem Medicaid |
$92.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$104.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$125.47
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$104.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.72
|
| Rate for Payer: Molina Healthcare Passport |
$92.86
|
| Rate for Payer: Multiplan PHCS |
$558.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$135.93
|
| Rate for Payer: UHCCP Medicaid |
$325.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$104.56
|
|
|
DUP SCAN OF AORTA - LIMITED
|
Facility
|
IP
|
$931.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
92100015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$279.30 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$744.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$809.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.39
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
DUP SCAN OF AORTA - LIMITED
|
Facility
|
OP
|
$931.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
92100015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem Medicaid |
$320.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Humana KY Medicaid |
$320.17
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$323.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$744.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$809.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.39
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
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 |
$199.75 |
| Rate for Payer: Aetna Commercial |
$183.42
|
| Rate for Payer: Ambetter Exchange |
$104.56
|
| Rate for Payer: Anthem Medicaid |
$92.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$104.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$125.47
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$104.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.56
|
| 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 |
$135.93
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$104.56
|
|
|
DUP SCAN OF AORTA - LIMITED(T
|
Facility
|
OP
|
$631.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
921T0015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$605.76 |
| Rate for Payer: Aetna Commercial |
$485.87
|
| Rate for Payer: Anthem Medicaid |
$217.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$492.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$315.50
|
| Rate for Payer: Cash Price |
$315.50
|
| Rate for Payer: Cigna Commercial |
$523.73
|
| Rate for Payer: First Health Commercial |
$599.45
|
| Rate for Payer: Humana Commercial |
$536.35
|
| Rate for Payer: Humana KY Medicaid |
$217.00
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$219.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$517.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$465.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$221.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$555.28
|
| Rate for Payer: Ohio Health Group HMO |
$473.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$504.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$435.39
|
| Rate for Payer: PHCS Commercial |
$605.76
|
| Rate for Payer: United Healthcare All Payer |
$555.28
|
|
|
DUP SCAN OF AORTA - LIMITED(T
|
Facility
|
IP
|
$631.00
|
|
|
Service Code
|
HCPCS 93979
|
| Hospital Charge Code |
921T0015
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$189.30 |
| Max. Negotiated Rate |
$605.76 |
| Rate for Payer: Aetna Commercial |
$485.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$492.18
|
| Rate for Payer: Cash Price |
$315.50
|
| Rate for Payer: Cigna Commercial |
$523.73
|
| Rate for Payer: First Health Commercial |
$599.45
|
| Rate for Payer: Humana Commercial |
$536.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$517.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$465.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$189.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$555.28
|
| Rate for Payer: Ohio Health Group HMO |
$473.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$504.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$435.39
|
| Rate for Payer: PHCS Commercial |
$605.76
|
| Rate for Payer: United Healthcare All Payer |
$555.28
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
921T0003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem Medicaid |
$103.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Humana KY Medicaid |
$103.51
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$104.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.69
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
921T0003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.69
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
921P0003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$266.25 |
| Rate for Payer: Aetna Commercial |
$249.25
|
| Rate for Payer: Ambetter Exchange |
$110.16
|
| Rate for Payer: Anthem Medicaid |
$89.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$110.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$110.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.19
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$205.36
|
| Rate for Payer: Healthspan PPO |
$266.25
|
| Rate for Payer: Humana Medicaid |
$89.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$110.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$110.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.84
|
| Rate for Payer: Molina Healthcare Passport |
$89.06
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.21
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$110.16
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Professional
|
Both
|
$551.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92100003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$330.60 |
| Rate for Payer: Aetna Commercial |
$249.25
|
| Rate for Payer: Ambetter Exchange |
$110.16
|
| Rate for Payer: Anthem Medicaid |
$89.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$110.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$110.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.19
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cigna Commercial |
$205.36
|
| Rate for Payer: Healthspan PPO |
$266.25
|
| Rate for Payer: Humana Medicaid |
$89.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$110.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$110.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.84
|
| Rate for Payer: Molina Healthcare Passport |
$89.06
|
| Rate for Payer: Multiplan PHCS |
$330.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.21
|
| Rate for Payer: UHCCP Medicaid |
$192.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$110.16
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92000006
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$87.30 |
| 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 |
$232.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$200.79
|
| Rate for Payer: PHCS Commercial |
$279.36
|
| Rate for Payer: United Healthcare All Payer |
$256.08
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
IP
|
$551.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92100003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$165.30 |
| Max. Negotiated Rate |
$528.96 |
| Rate for Payer: Aetna Commercial |
$424.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.78
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cigna Commercial |
$457.33
|
| Rate for Payer: First Health Commercial |
$523.45
|
| Rate for Payer: Humana Commercial |
$468.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$406.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.88
|
| Rate for Payer: Ohio Health Group HMO |
$413.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$479.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$380.19
|
| Rate for Payer: PHCS Commercial |
$528.96
|
| Rate for Payer: United Healthcare All Payer |
$484.88
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92000006
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Aetna Commercial |
$224.07
|
| Rate for Payer: Anthem Medicaid |
$100.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$145.50
|
| 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: Humana KY Medicaid |
$100.07
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$101.09
|
| 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 |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.08
|
| 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 |
$232.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$200.79
|
| Rate for Payer: PHCS Commercial |
$279.36
|
| Rate for Payer: United Healthcare All Payer |
$256.08
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
OP
|
$551.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92100003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$528.96 |
| Rate for Payer: Aetna Commercial |
$424.27
|
| Rate for Payer: Anthem Medicaid |
$189.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cigna Commercial |
$457.33
|
| Rate for Payer: First Health Commercial |
$523.45
|
| Rate for Payer: Humana Commercial |
$468.35
|
| Rate for Payer: Humana KY Medicaid |
$189.49
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$191.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$406.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$193.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.88
|
| Rate for Payer: Ohio Health Group HMO |
$413.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$479.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$380.19
|
| Rate for Payer: PHCS Commercial |
$528.96
|
| Rate for Payer: United Healthcare All Payer |
$484.88
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
921T0009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$152.00 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$152.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$152.00
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$153.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$155.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
921P0009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$306.90 |
| Rate for Payer: Aetna Commercial |
$270.01
|
| Rate for Payer: Ambetter Exchange |
$176.60
|
| Rate for Payer: Anthem Medicaid |
$137.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$176.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$176.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$211.92
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$306.90
|
| Rate for Payer: Healthspan PPO |
$288.43
|
| Rate for Payer: Humana Medicaid |
$137.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$176.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$176.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.77
|
| Rate for Payer: Molina Healthcare Passport |
$137.03
|
| Rate for Payer: Multiplan PHCS |
$87.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$229.58
|
| Rate for Payer: UHCCP Medicaid |
$50.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$176.60
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
OP
|
$587.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
92100009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$201.87 |
| Max. Negotiated Rate |
$563.52 |
| Rate for Payer: Aetna Commercial |
$451.99
|
| Rate for Payer: Anthem Medicaid |
$201.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$457.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$293.50
|
| Rate for Payer: Cash Price |
$293.50
|
| Rate for Payer: Cigna Commercial |
$487.21
|
| Rate for Payer: First Health Commercial |
$557.65
|
| Rate for Payer: Humana Commercial |
$498.95
|
| Rate for Payer: Humana KY Medicaid |
$201.87
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$203.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$481.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$433.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$205.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$516.56
|
| Rate for Payer: Ohio Health Group HMO |
$440.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$469.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$510.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$405.03
|
| Rate for Payer: PHCS Commercial |
$563.52
|
| Rate for Payer: United Healthcare All Payer |
$516.56
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
IP
|
$587.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
92100009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$176.10 |
| Max. Negotiated Rate |
$563.52 |
| Rate for Payer: Aetna Commercial |
$451.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$457.86
|
| Rate for Payer: Cash Price |
$293.50
|
| Rate for Payer: Cigna Commercial |
$487.21
|
| Rate for Payer: First Health Commercial |
$557.65
|
| Rate for Payer: Humana Commercial |
$498.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$481.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$433.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$176.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$516.56
|
| Rate for Payer: Ohio Health Group HMO |
$440.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$469.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$510.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$405.03
|
| Rate for Payer: PHCS Commercial |
$563.52
|
| Rate for Payer: United Healthcare All Payer |
$516.56
|
|
