|
GALAFLEX SLING INSERT (BILAT)
|
Professional
|
Both
|
$780.00
|
|
| Hospital Charge Code |
22200200
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$780.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$780.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Multiplan PHCS |
$468.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$546.00
|
| Rate for Payer: UHCCP Medicaid |
$273.00
|
|
|
GALAFLEX SLING INSERT (UNILAT)
|
Professional
|
Both
|
$390.00
|
|
| Hospital Charge Code |
22200199
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$390.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$273.00
|
| Rate for Payer: UHCCP Medicaid |
$136.50
|
|
|
GALAFLEX SLING INSRT(BILAT)-80
|
Professional
|
Both
|
$390.00
|
|
| Hospital Charge Code |
22200392
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$390.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$273.00
|
| Rate for Payer: UHCCP Medicaid |
$136.50
|
|
|
GALAFLEX SLING INSRT(UNILA)-80
|
Professional
|
Both
|
$195.00
|
|
| Hospital Charge Code |
22200391
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$68.25 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$195.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Multiplan PHCS |
$117.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$136.50
|
| Rate for Payer: UHCCP Medicaid |
$68.25
|
|
|
GALLIUM 68 NETSPOT
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
34000072
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
GALLIUM 68 NETSPOT
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
34000072
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
GALLIUM GA 67 PER MCI
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
34000063
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.40
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.30
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
GALLIUM GA 67 PER MCI
|
Facility
|
OP
|
$430.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
34000063
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem Medicaid |
$147.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.40
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Humana KY Medicaid |
$147.88
|
| Rate for Payer: Kentucky WC Medicaid |
$149.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.30
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
GALLIUM GA 67 PER MCI(T
|
Facility
|
OP
|
$430.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
340T0063
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem Medicaid |
$147.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.40
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Humana KY Medicaid |
$147.88
|
| Rate for Payer: Kentucky WC Medicaid |
$149.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.30
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
GALLIUM GA 67 PER MCI(T
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
340T0063
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.40
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.30
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
GALLIUM ILLUCCIX 1 MCI (5 MCI)
|
Facility
|
IP
|
$4,798.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
34000123
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$623.74 |
| Max. Negotiated Rate |
$4,606.08 |
| Rate for Payer: Aetna Commercial |
$3,694.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.44
|
| Rate for Payer: Cash Price |
$2,399.00
|
| Rate for Payer: Cigna Commercial |
$3,982.34
|
| Rate for Payer: First Health Commercial |
$4,558.10
|
| Rate for Payer: Humana Commercial |
$4,078.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,934.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,222.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$959.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$623.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,487.38
|
| Rate for Payer: PHCS Commercial |
$4,606.08
|
| Rate for Payer: United Healthcare All Payer |
$4,222.24
|
|
|
GALLIUM ILLUCCIX 1 MCI (5 MCI)
|
Professional
|
Both
|
$4,798.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
34000123
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,679.30 |
| Max. Negotiated Rate |
$4,798.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,798.00
|
| Rate for Payer: Cash Price |
$2,399.00
|
| Rate for Payer: Multiplan PHCS |
$2,878.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,358.60
|
| Rate for Payer: UHCCP Medicaid |
$1,679.30
|
|
|
GALLIUM ILLUCCIX 1 MCI (5 MCI)
|
Facility
|
OP
|
$4,798.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
34000123
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$623.74 |
| Max. Negotiated Rate |
$4,606.08 |
| Rate for Payer: Aetna Commercial |
$3,694.46
|
| Rate for Payer: Anthem Medicaid |
$1,650.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$991.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,388.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,338.77
|
| Rate for Payer: Cash Price |
$2,399.00
|
| Rate for Payer: Cash Price |
$2,399.00
|
| Rate for Payer: Cigna Commercial |
$3,982.34
|
| Rate for Payer: First Health Commercial |
$4,558.10
|
| Rate for Payer: Humana Commercial |
$4,078.30
|
| Rate for Payer: Humana KY Medicaid |
$1,650.03
|
| Rate for Payer: Humana Medicare Advantage |
$991.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,934.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,683.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,222.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$959.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$623.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,487.38
|
| Rate for Payer: PHCS Commercial |
$4,606.08
|
| Rate for Payer: United Healthcare All Payer |
$4,222.24
|
|
|
GALLIUM ILLUCCIX EACH ADD MCI
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
34000124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$1,388.35 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem Medicaid |
$323.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$991.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,388.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,338.77
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Humana KY Medicaid |
$323.27
|
| Rate for Payer: Humana Medicare Advantage |
$991.68
|
| Rate for Payer: Kentucky WC Medicaid |
$326.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$329.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.40
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
GALLIUM ILLUCCIX EACH ADD MCI
|
Facility
|
IP
|
$940.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
34000124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$902.40 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$282.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.40
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
GALLIUM ILLUCCIX EACH ADD MCI
|
Professional
|
Both
|
$940.00
|
|
|
Service Code
|
HCPCS A9596
|
| Hospital Charge Code |
34000124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$329.00 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$940.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Multiplan PHCS |
$564.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$658.00
|
| Rate for Payer: UHCCP Medicaid |
$329.00
|
|
|
GALLIUM SCAN WHOLE BODY
|
Facility
|
IP
|
$1,810.00
|
|
|
Service Code
|
HCPCS 78802
|
| Hospital Charge Code |
34000035
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$235.30 |
| Max. Negotiated Rate |
$1,737.60 |
| Rate for Payer: Aetna Commercial |
$1,393.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.80
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$1,502.30
|
| Rate for Payer: First Health Commercial |
$1,719.50
|
| Rate for Payer: Humana Commercial |
$1,538.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.10
|
| Rate for Payer: PHCS Commercial |
$1,737.60
|
| Rate for Payer: United Healthcare All Payer |
$1,592.80
|
|
|
GALLIUM SCAN WHOLE BODY
|
Facility
|
OP
|
$1,810.00
|
|
|
Service Code
|
HCPCS 78802
|
| Hospital Charge Code |
34000035
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$235.30 |
| Max. Negotiated Rate |
$1,737.60 |
| Rate for Payer: Aetna Commercial |
$1,393.70
|
| Rate for Payer: Anthem Medicaid |
$622.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,227.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,719.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,657.69
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$1,502.30
|
| Rate for Payer: First Health Commercial |
$1,719.50
|
| Rate for Payer: Humana Commercial |
$1,538.50
|
| Rate for Payer: Humana KY Medicaid |
$622.46
|
| Rate for Payer: Humana Medicare Advantage |
$1,227.92
|
| Rate for Payer: Kentucky WC Medicaid |
$628.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.10
|
| Rate for Payer: PHCS Commercial |
$1,737.60
|
| Rate for Payer: United Healthcare All Payer |
$1,592.80
|
|
|
GALLIUM SCAN WHOLE BODY
|
Professional
|
Both
|
$1,810.00
|
|
|
Service Code
|
HCPCS 78802
|
| Hospital Charge Code |
34000035
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$1,810.00 |
| Rate for Payer: Aetna Commercial |
$479.00
|
| Rate for Payer: Anthem Medicaid |
$234.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,810.00
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cash Price |
$905.00
|
| Rate for Payer: Cigna Commercial |
$411.57
|
| Rate for Payer: Healthspan PPO |
$478.75
|
| Rate for Payer: Humana Medicaid |
$234.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.84
|
| Rate for Payer: Molina Healthcare Passport |
$234.16
|
| Rate for Payer: Multiplan PHCS |
$1,086.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,267.00
|
| Rate for Payer: UHCCP Medicaid |
$633.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.50
|
|
|
GALLIUM SCAN WHOLE BODY(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 78802
|
| Hospital Charge Code |
340P0035
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$479.00 |
| Rate for Payer: Aetna Commercial |
$479.00
|
| Rate for Payer: Anthem Medicaid |
$234.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$411.57
|
| Rate for Payer: Healthspan PPO |
$478.75
|
| Rate for Payer: Humana Medicaid |
$234.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.84
|
| Rate for Payer: Molina Healthcare Passport |
$234.16
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.50
|
|
|
GALLIUM SCAN WHOLE BODY(T
|
Facility
|
OP
|
$1,635.00
|
|
|
Service Code
|
HCPCS 78802
|
| Hospital Charge Code |
340T0035
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$212.55 |
| Max. Negotiated Rate |
$1,719.09 |
| Rate for Payer: Aetna Commercial |
$1,258.95
|
| Rate for Payer: Anthem Medicaid |
$562.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,227.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,275.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,719.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,657.69
|
| Rate for Payer: Cash Price |
$817.50
|
| Rate for Payer: Cash Price |
$817.50
|
| Rate for Payer: Cigna Commercial |
$1,357.05
|
| Rate for Payer: First Health Commercial |
$1,553.25
|
| Rate for Payer: Humana Commercial |
$1,389.75
|
| Rate for Payer: Humana KY Medicaid |
$562.28
|
| Rate for Payer: Humana Medicare Advantage |
$1,227.92
|
| Rate for Payer: Kentucky WC Medicaid |
$568.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,340.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,206.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$573.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,438.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,226.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$327.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$506.85
|
| Rate for Payer: PHCS Commercial |
$1,569.60
|
| Rate for Payer: United Healthcare All Payer |
$1,438.80
|
|
|
GALLIUM SCAN WHOLE BODY(T
|
Facility
|
IP
|
$1,635.00
|
|
|
Service Code
|
HCPCS 78802
|
| Hospital Charge Code |
340T0035
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$212.55 |
| Max. Negotiated Rate |
$1,569.60 |
| Rate for Payer: Aetna Commercial |
$1,258.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,275.30
|
| Rate for Payer: Cash Price |
$817.50
|
| Rate for Payer: Cigna Commercial |
$1,357.05
|
| Rate for Payer: First Health Commercial |
$1,553.25
|
| Rate for Payer: Humana Commercial |
$1,389.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,340.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,206.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$490.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,438.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,226.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$327.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$506.85
|
| Rate for Payer: PHCS Commercial |
$1,569.60
|
| Rate for Payer: United Healthcare All Payer |
$1,438.80
|
|
|
GAMASTAN 1ML (10ML SDV)
|
Facility
|
OP
|
$1,055.39
|
|
|
Service Code
|
HCPCS J1560
|
| Hospital Charge Code |
25002086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$1,013.17 |
| Rate for Payer: Aetna Commercial |
$812.65
|
| Rate for Payer: Anthem Medicaid |
$362.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$507.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$823.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$710.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$684.80
|
| Rate for Payer: Cash Price |
$527.70
|
| Rate for Payer: Cash Price |
$527.70
|
| Rate for Payer: Cigna Commercial |
$875.97
|
| Rate for Payer: First Health Commercial |
$1,002.62
|
| Rate for Payer: Humana Commercial |
$897.08
|
| Rate for Payer: Humana KY Medicaid |
$362.95
|
| Rate for Payer: Humana Medicare Advantage |
$507.26
|
| Rate for Payer: Kentucky WC Medicaid |
$366.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$865.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$778.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$608.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$928.74
|
| Rate for Payer: Ohio Health Group HMO |
$791.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.17
|
| Rate for Payer: PHCS Commercial |
$1,013.17
|
| Rate for Payer: United Healthcare All Payer |
$928.74
|
|
|
GAMASTAN 1ML (10ML SDV)
|
Facility
|
IP
|
$1,055.39
|
|
|
Service Code
|
HCPCS J1560
|
| Hospital Charge Code |
25002086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$1,013.17 |
| Rate for Payer: Aetna Commercial |
$812.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$823.20
|
| Rate for Payer: Cash Price |
$527.70
|
| Rate for Payer: Cigna Commercial |
$875.97
|
| Rate for Payer: First Health Commercial |
$1,002.62
|
| Rate for Payer: Humana Commercial |
$897.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$865.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$778.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$316.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$928.74
|
| Rate for Payer: Ohio Health Group HMO |
$791.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.17
|
| Rate for Payer: PHCS Commercial |
$1,013.17
|
| Rate for Payer: United Healthcare All Payer |
$928.74
|
|
|
GAMASTAN VIAL (2ML)
|
Facility
|
OP
|
$532.04
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
25002079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.73 |
| Max. Negotiated Rate |
$510.76 |
| Rate for Payer: Aetna Commercial |
$409.67
|
| Rate for Payer: Anthem Medicaid |
$182.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$50.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.99
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$71.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.48
|
| Rate for Payer: Cash Price |
$266.02
|
| Rate for Payer: Cash Price |
$266.02
|
| Rate for Payer: Cigna Commercial |
$441.59
|
| Rate for Payer: First Health Commercial |
$505.44
|
| Rate for Payer: Humana Commercial |
$452.23
|
| Rate for Payer: Humana KY Medicaid |
$182.97
|
| Rate for Payer: Humana Medicare Advantage |
$50.73
|
| Rate for Payer: Kentucky WC Medicaid |
$184.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$436.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$392.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$468.20
|
| Rate for Payer: Ohio Health Group HMO |
$399.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$164.93
|
| Rate for Payer: PHCS Commercial |
$510.76
|
| Rate for Payer: United Healthcare All Payer |
$468.20
|
|
