|
SAVI-06 GAMMA KIT
|
Facility
|
IP
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000266
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.35 |
| Max. Negotiated Rate |
$11,035.20 |
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Aetna Commercial |
$9,660.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,786.42
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$6,273.35
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: Cigna Commercial |
$10,413.75
|
| Rate for Payer: First Health Commercial |
$11,919.36
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$10,664.69
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,288.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,259.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,764.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,041.09
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$9,410.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: PHCS Commercial |
$12,044.82
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
| Rate for Payer: United Healthcare All Payer |
$11,041.09
|
|
|
SAVI-06 MINIGAMMA KIT
|
Facility
|
IP
|
$12,546.69
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000267
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,631.07 |
| Max. Negotiated Rate |
$12,044.82 |
| Rate for Payer: Aetna Commercial |
$9,660.95
|
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,786.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$6,273.35
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: Cigna Commercial |
$10,413.75
|
| Rate for Payer: First Health Commercial |
$11,919.36
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$10,664.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,288.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,259.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,764.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,041.09
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$9,410.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.47
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: PHCS Commercial |
$12,044.82
|
| Rate for Payer: United Healthcare All Payer |
$11,041.09
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
|
SAVI-06 MINIGAMMA KIT
|
Professional
|
Both
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000267
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,023.25 |
| Max. Negotiated Rate |
$11,495.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$11,495.00
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Multiplan PHCS |
$6,897.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8,046.50
|
| Rate for Payer: UHCCP Medicaid |
$4,023.25
|
|
|
SAVI-06 MINIGAMMA KIT
|
Facility
|
OP
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000267
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.35 |
| Max. Negotiated Rate |
$11,035.20 |
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Aetna Commercial |
$9,660.95
|
| Rate for Payer: Anthem Medicaid |
$3,953.13
|
| Rate for Payer: Anthem Medicaid |
$4,314.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,786.42
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$6,273.35
|
| Rate for Payer: Cigna Commercial |
$10,413.75
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: First Health Commercial |
$11,919.36
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$10,664.69
|
| Rate for Payer: Humana KY Medicaid |
$3,953.13
|
| Rate for Payer: Humana KY Medicaid |
$4,314.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.72
|
| Rate for Payer: Kentucky WC Medicaid |
$3,993.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,288.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,259.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,764.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,032.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,401.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,041.09
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$9,410.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.47
|
| Rate for Payer: PHCS Commercial |
$12,044.82
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: United Healthcare All Payer |
$11,041.09
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
|
SAVI-08 GAMMA KIT
|
Professional
|
Both
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,023.25 |
| Max. Negotiated Rate |
$11,495.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$11,495.00
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Multiplan PHCS |
$6,897.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8,046.50
|
| Rate for Payer: UHCCP Medicaid |
$4,023.25
|
|
|
SAVI-08 GAMMA KIT
|
Facility
|
OP
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.35 |
| Max. Negotiated Rate |
$11,035.20 |
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Aetna Commercial |
$9,005.15
|
| Rate for Payer: Anthem Medicaid |
$3,953.13
|
| Rate for Payer: Anthem Medicaid |
$4,021.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.10
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$5,847.50
|
| Rate for Payer: Cigna Commercial |
$9,706.85
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: First Health Commercial |
$11,110.25
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$9,940.75
|
| Rate for Payer: Humana KY Medicaid |
$3,953.13
|
| Rate for Payer: Humana KY Medicaid |
$4,021.91
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,993.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,032.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,339.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,520.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,625.45
|
| Rate for Payer: PHCS Commercial |
$11,227.20
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: United Healthcare All Payer |
$10,291.60
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
|
SAVI-08 GAMMA KIT
|
Facility
|
IP
|
$11,695.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000268
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,520.35 |
| Max. Negotiated Rate |
$11,227.20 |
| Rate for Payer: Aetna Commercial |
$9,005.15
|
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$5,847.50
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: Cigna Commercial |
$9,706.85
|
| Rate for Payer: First Health Commercial |
$11,110.25
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$9,940.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,339.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,520.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,625.45
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: PHCS Commercial |
$11,227.20
|
| Rate for Payer: United Healthcare All Payer |
$10,291.60
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
|
SAVI-10 GAMMA KIT
|
Professional
|
Both
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000269
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,023.25 |
| Max. Negotiated Rate |
$11,495.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$11,495.00
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Multiplan PHCS |
$6,897.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8,046.50
|
| Rate for Payer: UHCCP Medicaid |
$4,023.25
|
|
|
SAVI-10 GAMMA KIT
|
Facility
|
OP
|
$11,495.00
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000269
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,494.35 |
| Max. Negotiated Rate |
$11,035.20 |
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Aetna Commercial |
$9,321.89
|
| Rate for Payer: Anthem Medicaid |
$3,953.13
|
| Rate for Payer: Anthem Medicaid |
$4,163.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,442.95
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$6,053.18
|
| Rate for Payer: Cigna Commercial |
$10,048.27
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: First Health Commercial |
$11,501.03
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$10,290.40
|
| Rate for Payer: Humana KY Medicaid |
$3,953.13
|
| Rate for Payer: Humana KY Medicaid |
$4,163.37
|
| Rate for Payer: Kentucky WC Medicaid |
$4,205.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,993.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,927.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,934.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,631.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,032.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,246.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,653.59
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$9,079.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,421.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,573.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,752.97
|
| Rate for Payer: PHCS Commercial |
$11,622.10
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: United Healthcare All Payer |
$10,653.59
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
|
SAVI-10 GAMMA KIT
|
Facility
|
IP
|
$12,106.35
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000269
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,573.83 |
| Max. Negotiated Rate |
$11,622.10 |
| Rate for Payer: Aetna Commercial |
$9,321.89
|
| Rate for Payer: Aetna Commercial |
$8,851.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,442.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,966.10
|
| Rate for Payer: Cash Price |
$5,747.50
|
| Rate for Payer: Cash Price |
$6,053.18
|
| Rate for Payer: Cigna Commercial |
$9,540.85
|
| Rate for Payer: Cigna Commercial |
$10,048.27
|
| Rate for Payer: First Health Commercial |
$11,501.03
|
| Rate for Payer: First Health Commercial |
$10,920.25
|
| Rate for Payer: Humana Commercial |
$9,770.75
|
| Rate for Payer: Humana Commercial |
$10,290.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,927.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,425.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,934.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,483.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,631.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,448.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,115.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,653.59
|
| Rate for Payer: Ohio Health Group HMO |
$8,621.25
|
| Rate for Payer: Ohio Health Group HMO |
$9,079.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,421.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,299.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,573.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,563.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,752.97
|
| Rate for Payer: PHCS Commercial |
$11,035.20
|
| Rate for Payer: PHCS Commercial |
$11,622.10
|
| Rate for Payer: United Healthcare All Payer |
$10,653.59
|
| Rate for Payer: United Healthcare All Payer |
$10,115.60
|
|
|
SAVION FLEX WIRE 300CM
|
Facility
|
IP
|
$2,089.02
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.57 |
| Max. Negotiated Rate |
$2,005.46 |
| Rate for Payer: Aetna Commercial |
$1,608.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,629.44
|
| Rate for Payer: Cash Price |
$1,044.51
|
| Rate for Payer: Cigna Commercial |
$1,733.89
|
| Rate for Payer: First Health Commercial |
$1,984.57
|
| Rate for Payer: Humana Commercial |
$1,775.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,713.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,541.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$626.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,838.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,566.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$647.60
|
| Rate for Payer: PHCS Commercial |
$2,005.46
|
| Rate for Payer: United Healthcare All Payer |
$1,838.34
|
|
|
SAVION FLEX WIRE 300CM
|
Facility
|
OP
|
$2,089.02
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.57 |
| Max. Negotiated Rate |
$2,005.46 |
| Rate for Payer: Aetna Commercial |
$1,608.55
|
| Rate for Payer: Anthem Medicaid |
$718.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,629.44
|
| Rate for Payer: Cash Price |
$1,044.51
|
| Rate for Payer: Cigna Commercial |
$1,733.89
|
| Rate for Payer: First Health Commercial |
$1,984.57
|
| Rate for Payer: Humana Commercial |
$1,775.67
|
| Rate for Payer: Humana KY Medicaid |
$718.41
|
| Rate for Payer: Kentucky WC Medicaid |
$725.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,713.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,541.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$626.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$732.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,838.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,566.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$647.60
|
| Rate for Payer: PHCS Commercial |
$2,005.46
|
| Rate for Payer: United Healthcare All Payer |
$1,838.34
|
|
|
SBRT MANAGEMENT
|
Facility
|
OP
|
$1,575.00
|
|
|
Service Code
|
HCPCS 77435
|
| Hospital Charge Code |
33300040
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: Aetna Commercial |
$1,212.75
|
| Rate for Payer: Anthem Medicaid |
$541.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.50
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cigna Commercial |
$1,307.25
|
| Rate for Payer: First Health Commercial |
$1,496.25
|
| Rate for Payer: Humana Commercial |
$1,338.75
|
| Rate for Payer: Humana KY Medicaid |
$541.64
|
| Rate for Payer: Kentucky WC Medicaid |
$547.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$472.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$552.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,386.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,181.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.25
|
| Rate for Payer: PHCS Commercial |
$1,512.00
|
| Rate for Payer: United Healthcare All Payer |
$1,386.00
|
|
|
SBRT MANAGEMENT
|
Professional
|
Both
|
$1,575.00
|
|
|
Service Code
|
HCPCS 77435
|
| Hospital Charge Code |
33300040
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$508.67 |
| Max. Negotiated Rate |
$2,595.87 |
| Rate for Payer: Aetna Commercial |
$1,052.99
|
| Rate for Payer: Anthem Medicaid |
$508.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,575.00
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cigna Commercial |
$983.45
|
| Rate for Payer: Healthspan PPO |
$888.00
|
| Rate for Payer: Humana Medicaid |
$508.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,595.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$518.84
|
| Rate for Payer: Molina Healthcare Passport |
$508.67
|
| Rate for Payer: Multiplan PHCS |
$945.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,102.50
|
| Rate for Payer: UHCCP Medicaid |
$551.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$513.76
|
|
|
SBRT MANAGEMENT
|
Facility
|
IP
|
$1,575.00
|
|
|
Service Code
|
HCPCS 77435
|
| Hospital Charge Code |
33300040
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: Aetna Commercial |
$1,212.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.50
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cigna Commercial |
$1,307.25
|
| Rate for Payer: First Health Commercial |
$1,496.25
|
| Rate for Payer: Humana Commercial |
$1,338.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$472.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,386.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,181.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.25
|
| Rate for Payer: PHCS Commercial |
$1,512.00
|
| Rate for Payer: United Healthcare All Payer |
$1,386.00
|
|
|
SBRT MANAGEMENT(P
|
Professional
|
Both
|
$1,575.00
|
|
|
Service Code
|
HCPCS 77435
|
| Hospital Charge Code |
333P0040
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$508.67 |
| Max. Negotiated Rate |
$2,595.87 |
| Rate for Payer: Aetna Commercial |
$1,052.99
|
| Rate for Payer: Anthem Medicaid |
$508.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,575.00
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cigna Commercial |
$983.45
|
| Rate for Payer: Healthspan PPO |
$888.00
|
| Rate for Payer: Humana Medicaid |
$508.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,595.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$518.84
|
| Rate for Payer: Molina Healthcare Passport |
$508.67
|
| Rate for Payer: Multiplan PHCS |
$945.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,102.50
|
| Rate for Payer: UHCCP Medicaid |
$551.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$513.76
|
|
|
SBSQ NB EM PER DAY HOSP
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 99462
|
| Hospital Charge Code |
51000118
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.63 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$47.38
|
| Rate for Payer: Anthem Medicaid |
$24.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$48.22
|
| Rate for Payer: Healthspan PPO |
$35.22
|
| Rate for Payer: Humana Medicaid |
$24.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.12
|
| Rate for Payer: Molina Healthcare Passport |
$24.63
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$24.88
|
|
|
SBSQ NB EM PER DAY HOSP
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 99462
|
| Hospital Charge Code |
51000118
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
SBSQ NB EM PER DAY HOSP
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 99462
|
| Hospital Charge Code |
51000118
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
SBSQ NB EM PER DAY HOSP(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 99462
|
| Hospital Charge Code |
510P0118
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.63 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$47.38
|
| Rate for Payer: Anthem Medicaid |
$24.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$48.22
|
| Rate for Payer: Healthspan PPO |
$35.22
|
| Rate for Payer: Humana Medicaid |
$24.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.12
|
| Rate for Payer: Molina Healthcare Passport |
$24.63
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$24.88
|
|
|
SCALLOPS IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000909
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SCALLOPS IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000909
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SCALP COOL 1ST MEAS&CALBRJ
|
Professional
|
Both
|
$2,650.00
|
|
|
Service Code
|
HCPCS 0662T
|
| Hospital Charge Code |
76102918
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$927.50 |
| Max. Negotiated Rate |
$2,650.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,650.00
|
| Rate for Payer: Cash Price |
$1,325.00
|
| Rate for Payer: Multiplan PHCS |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,855.00
|
| Rate for Payer: UHCCP Medicaid |
$927.50
|
|
|
SCALP COOL 1ST MEAS&CALBRJ
|
Facility
|
IP
|
$2,650.00
|
|
|
Service Code
|
HCPCS 0662T
|
| Hospital Charge Code |
76102918
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$344.50 |
| Max. Negotiated Rate |
$2,544.00 |
| Rate for Payer: Aetna Commercial |
$2,040.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,067.00
|
| Rate for Payer: Cash Price |
$1,325.00
|
| Rate for Payer: Cigna Commercial |
$2,199.50
|
| Rate for Payer: First Health Commercial |
$2,517.50
|
| Rate for Payer: Humana Commercial |
$2,252.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,173.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,955.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$795.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,332.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$344.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$821.50
|
| Rate for Payer: PHCS Commercial |
$2,544.00
|
| Rate for Payer: United Healthcare All Payer |
$2,332.00
|
|
|
SCALP COOL 1ST MEAS&CALBRJ
|
Facility
|
OP
|
$2,650.00
|
|
|
Service Code
|
HCPCS 0662T
|
| Hospital Charge Code |
76102918
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$344.50 |
| Max. Negotiated Rate |
$2,544.00 |
| Rate for Payer: Aetna Commercial |
$2,040.50
|
| Rate for Payer: Anthem Medicaid |
$911.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,134.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,067.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,588.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,532.18
|
| Rate for Payer: Cash Price |
$1,325.00
|
| Rate for Payer: Cash Price |
$1,325.00
|
| Rate for Payer: Cigna Commercial |
$2,199.50
|
| Rate for Payer: First Health Commercial |
$2,517.50
|
| Rate for Payer: Humana Commercial |
$2,252.50
|
| Rate for Payer: Humana KY Medicaid |
$911.34
|
| Rate for Payer: Humana Medicare Advantage |
$1,134.95
|
| Rate for Payer: Kentucky WC Medicaid |
$920.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,173.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,955.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,361.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$929.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,332.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$344.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$821.50
|
| Rate for Payer: PHCS Commercial |
$2,544.00
|
| Rate for Payer: United Healthcare All Payer |
$2,332.00
|
|
