|
GAMASTAN 1ML (10ML SDV)
|
Facility
|
IP
|
$1,055.39
|
|
|
Service Code
|
HCPCS J1560
|
| Hospital Charge Code |
25002086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$316.62 |
| 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 |
$844.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$918.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$728.22
|
| Rate for Payer: PHCS Commercial |
$1,013.17
|
| Rate for Payer: United Healthcare All Payer |
$928.74
|
|
|
GAMASTAN VIAL (2ML)
|
Facility
|
IP
|
$532.04
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
25002079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$159.61 |
| Max. Negotiated Rate |
$510.76 |
| Rate for Payer: Aetna Commercial |
$409.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.99
|
| 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: 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 |
$159.61
|
| 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 |
$425.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$462.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$367.11
|
| Rate for Payer: PHCS Commercial |
$510.76
|
| Rate for Payer: United Healthcare All Payer |
$468.20
|
|
|
GAMASTAN VIAL (2ML)
|
Facility
|
OP
|
$532.04
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
25002079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.42 |
| 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 |
$48.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.99
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.37
|
| 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 |
$48.42
|
| 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 |
$58.10
|
| 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 |
$425.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$462.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$367.11
|
| Rate for Payer: PHCS Commercial |
$510.76
|
| Rate for Payer: United Healthcare All Payer |
$468.20
|
|
|
GAMMA-BSM KIT 10CC
|
Facility
|
OP
|
$22,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,855.00 |
| Max. Negotiated Rate |
$21,936.00 |
| Rate for Payer: Aetna Commercial |
$17,594.50
|
| Rate for Payer: Anthem Medicaid |
$7,858.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,823.00
|
| Rate for Payer: Cash Price |
$11,425.00
|
| Rate for Payer: Cigna Commercial |
$18,965.50
|
| Rate for Payer: First Health Commercial |
$21,707.50
|
| Rate for Payer: Humana Commercial |
$19,422.50
|
| Rate for Payer: Humana KY Medicaid |
$7,858.11
|
| Rate for Payer: Kentucky WC Medicaid |
$7,938.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,737.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,863.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,855.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,015.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,108.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,137.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,879.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,766.50
|
| Rate for Payer: PHCS Commercial |
$21,936.00
|
| Rate for Payer: United Healthcare All Payer |
$20,108.00
|
|
|
GAMMA-BSM KIT 10CC
|
Facility
|
IP
|
$22,850.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,855.00 |
| Max. Negotiated Rate |
$21,936.00 |
| Rate for Payer: Aetna Commercial |
$17,594.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,823.00
|
| Rate for Payer: Cash Price |
$11,425.00
|
| Rate for Payer: Cigna Commercial |
$18,965.50
|
| Rate for Payer: First Health Commercial |
$21,707.50
|
| Rate for Payer: Humana Commercial |
$19,422.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,737.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,863.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,855.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,108.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,137.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,879.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,766.50
|
| Rate for Payer: PHCS Commercial |
$21,936.00
|
| Rate for Payer: United Healthcare All Payer |
$20,108.00
|
|
|
GAMMA- BSM KIT 2.5CC
|
Facility
|
IP
|
$11,397.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,419.35 |
| Max. Negotiated Rate |
$10,941.93 |
| Rate for Payer: Aetna Commercial |
$8,776.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,890.32
|
| Rate for Payer: Cash Price |
$5,698.92
|
| Rate for Payer: Cigna Commercial |
$9,460.21
|
| Rate for Payer: First Health Commercial |
$10,827.95
|
| Rate for Payer: Humana Commercial |
$9,688.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,346.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,411.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,419.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,030.10
|
| Rate for Payer: Ohio Health Group HMO |
$8,548.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,118.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,916.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,864.51
|
| Rate for Payer: PHCS Commercial |
$10,941.93
|
| Rate for Payer: United Healthcare All Payer |
$10,030.10
|
|
|
GAMMA- BSM KIT 2.5CC
|
Facility
|
OP
|
$11,397.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,419.35 |
| Max. Negotiated Rate |
$10,941.93 |
| Rate for Payer: Aetna Commercial |
$8,776.34
|
| Rate for Payer: Anthem Medicaid |
$3,919.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,890.32
|
| Rate for Payer: Cash Price |
$5,698.92
|
| Rate for Payer: Cigna Commercial |
$9,460.21
|
| Rate for Payer: First Health Commercial |
$10,827.95
|
| Rate for Payer: Humana Commercial |
$9,688.16
|
| Rate for Payer: Humana KY Medicaid |
$3,919.72
|
| Rate for Payer: Kentucky WC Medicaid |
$3,959.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,346.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,411.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,419.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,998.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,030.10
|
| Rate for Payer: Ohio Health Group HMO |
$8,548.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,118.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,916.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,864.51
|
| Rate for Payer: PHCS Commercial |
$10,941.93
|
| Rate for Payer: United Healthcare All Payer |
$10,030.10
|
|
|
GAMMA-BSM KIT 5CC
|
Facility
|
OP
|
$15,914.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,774.32 |
| Max. Negotiated Rate |
$15,277.82 |
| Rate for Payer: Aetna Commercial |
$12,254.09
|
| Rate for Payer: Anthem Medicaid |
$5,472.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,413.23
|
| Rate for Payer: Cash Price |
$7,957.20
|
| Rate for Payer: Cigna Commercial |
$13,208.95
|
| Rate for Payer: First Health Commercial |
$15,118.68
|
| Rate for Payer: Humana Commercial |
$13,527.24
|
| Rate for Payer: Humana KY Medicaid |
$5,472.96
|
| Rate for Payer: Kentucky WC Medicaid |
$5,528.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,049.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,744.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,774.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,582.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,004.67
|
| Rate for Payer: Ohio Health Group HMO |
$11,935.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,731.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,845.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,980.94
|
| Rate for Payer: PHCS Commercial |
$15,277.82
|
| Rate for Payer: United Healthcare All Payer |
$14,004.67
|
|
|
GAMMA-BSM KIT 5CC
|
Facility
|
IP
|
$15,914.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,774.32 |
| Max. Negotiated Rate |
$15,277.82 |
| Rate for Payer: Aetna Commercial |
$12,254.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,413.23
|
| Rate for Payer: Cash Price |
$7,957.20
|
| Rate for Payer: Cigna Commercial |
$13,208.95
|
| Rate for Payer: First Health Commercial |
$15,118.68
|
| Rate for Payer: Humana Commercial |
$13,527.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,049.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,744.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,774.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,004.67
|
| Rate for Payer: Ohio Health Group HMO |
$11,935.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,731.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,845.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,980.94
|
| Rate for Payer: PHCS Commercial |
$15,277.82
|
| Rate for Payer: United Healthcare All Payer |
$14,004.67
|
|
|
GAMMAGARD 500mg(10gm) SDV
|
Facility
|
OP
|
$9,516.25
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$9,135.60 |
| Rate for Payer: Aetna Commercial |
$7,327.51
|
| Rate for Payer: Anthem Medicaid |
$3,272.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,422.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.53
|
| Rate for Payer: Cash Price |
$4,758.12
|
| Rate for Payer: Cash Price |
$4,758.12
|
| Rate for Payer: Cigna Commercial |
$7,898.49
|
| Rate for Payer: First Health Commercial |
$9,040.44
|
| Rate for Payer: Humana Commercial |
$8,088.81
|
| Rate for Payer: Humana KY Medicaid |
$3,272.64
|
| Rate for Payer: Humana Medicare Advantage |
$47.80
|
| Rate for Payer: Kentucky WC Medicaid |
$3,305.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,803.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,022.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,338.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,374.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,137.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,613.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,279.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,566.21
|
| Rate for Payer: PHCS Commercial |
$9,135.60
|
| Rate for Payer: United Healthcare All Payer |
$8,374.30
|
|
|
GAMMAGARD 500mg(10gm) SDV
|
Facility
|
IP
|
$9,516.25
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,854.88 |
| Max. Negotiated Rate |
$9,135.60 |
| Rate for Payer: Aetna Commercial |
$7,327.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,422.68
|
| Rate for Payer: Cash Price |
$4,758.12
|
| Rate for Payer: Cigna Commercial |
$7,898.49
|
| Rate for Payer: First Health Commercial |
$9,040.44
|
| Rate for Payer: Humana Commercial |
$8,088.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,803.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,022.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,854.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,374.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,137.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,613.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,279.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,566.21
|
| Rate for Payer: PHCS Commercial |
$9,135.60
|
| Rate for Payer: United Healthcare All Payer |
$8,374.30
|
|
|
GAMMAGARD 500mg(1gm) SDV
|
Facility
|
OP
|
$951.62
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25003837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$913.56 |
| Rate for Payer: Aetna Commercial |
$732.75
|
| Rate for Payer: Anthem Medicaid |
$327.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$742.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.53
|
| Rate for Payer: Cash Price |
$475.81
|
| Rate for Payer: Cash Price |
$475.81
|
| Rate for Payer: Cigna Commercial |
$789.84
|
| Rate for Payer: First Health Commercial |
$904.04
|
| Rate for Payer: Humana Commercial |
$808.88
|
| Rate for Payer: Humana KY Medicaid |
$327.26
|
| Rate for Payer: Humana Medicare Advantage |
$47.80
|
| Rate for Payer: Kentucky WC Medicaid |
$330.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$780.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$702.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$333.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$837.43
|
| Rate for Payer: Ohio Health Group HMO |
$713.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$761.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$827.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$656.62
|
| Rate for Payer: PHCS Commercial |
$913.56
|
| Rate for Payer: United Healthcare All Payer |
$837.43
|
|
|
GAMMAGARD 500mg(1gm) SDV
|
Facility
|
IP
|
$951.62
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25003837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$285.49 |
| Max. Negotiated Rate |
$913.56 |
| Rate for Payer: Aetna Commercial |
$732.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$742.26
|
| Rate for Payer: Cash Price |
$475.81
|
| Rate for Payer: Cigna Commercial |
$789.84
|
| Rate for Payer: First Health Commercial |
$904.04
|
| Rate for Payer: Humana Commercial |
$808.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$780.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$702.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$285.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$837.43
|
| Rate for Payer: Ohio Health Group HMO |
$713.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$761.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$827.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$656.62
|
| Rate for Payer: PHCS Commercial |
$913.56
|
| Rate for Payer: United Healthcare All Payer |
$837.43
|
|
|
GAMMAGARD 500mg(20gm) SDV
|
Facility
|
OP
|
$19,032.49
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$18,271.19 |
| Rate for Payer: Aetna Commercial |
$14,655.02
|
| Rate for Payer: Anthem Medicaid |
$6,545.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,845.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.53
|
| Rate for Payer: Cash Price |
$9,516.25
|
| Rate for Payer: Cash Price |
$9,516.25
|
| Rate for Payer: Cigna Commercial |
$15,796.97
|
| Rate for Payer: First Health Commercial |
$18,080.87
|
| Rate for Payer: Humana Commercial |
$16,177.62
|
| Rate for Payer: Humana KY Medicaid |
$6,545.27
|
| Rate for Payer: Humana Medicare Advantage |
$47.80
|
| Rate for Payer: Kentucky WC Medicaid |
$6,611.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,606.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,045.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,676.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,748.59
|
| Rate for Payer: Ohio Health Group HMO |
$14,274.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,225.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,558.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,132.42
|
| Rate for Payer: PHCS Commercial |
$18,271.19
|
| Rate for Payer: United Healthcare All Payer |
$16,748.59
|
|
|
GAMMAGARD 500mg(20gm) SDV
|
Facility
|
IP
|
$19,032.49
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,709.75 |
| Max. Negotiated Rate |
$18,271.19 |
| Rate for Payer: Aetna Commercial |
$14,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,845.34
|
| Rate for Payer: Cash Price |
$9,516.25
|
| Rate for Payer: Cigna Commercial |
$15,796.97
|
| Rate for Payer: First Health Commercial |
$18,080.87
|
| Rate for Payer: Humana Commercial |
$16,177.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,606.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,045.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,709.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,748.59
|
| Rate for Payer: Ohio Health Group HMO |
$14,274.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,225.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,558.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,132.42
|
| Rate for Payer: PHCS Commercial |
$18,271.19
|
| Rate for Payer: United Healthcare All Payer |
$16,748.59
|
|
|
GAMMAGARD 500mg(2.5gm) SDV
|
Facility
|
IP
|
$2,379.09
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$713.73 |
| Max. Negotiated Rate |
$2,283.93 |
| Rate for Payer: Aetna Commercial |
$1,831.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,855.69
|
| Rate for Payer: Cash Price |
$1,189.55
|
| Rate for Payer: Cigna Commercial |
$1,974.64
|
| Rate for Payer: First Health Commercial |
$2,260.14
|
| Rate for Payer: Humana Commercial |
$2,022.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,950.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,755.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$713.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,093.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,784.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,903.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,069.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,641.57
|
| Rate for Payer: PHCS Commercial |
$2,283.93
|
| Rate for Payer: United Healthcare All Payer |
$2,093.60
|
|
|
GAMMAGARD 500mg(2.5gm) SDV
|
Facility
|
OP
|
$2,379.09
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$2,283.93 |
| Rate for Payer: Aetna Commercial |
$1,831.90
|
| Rate for Payer: Anthem Medicaid |
$818.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,855.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.53
|
| Rate for Payer: Cash Price |
$1,189.55
|
| Rate for Payer: Cash Price |
$1,189.55
|
| Rate for Payer: Cigna Commercial |
$1,974.64
|
| Rate for Payer: First Health Commercial |
$2,260.14
|
| Rate for Payer: Humana Commercial |
$2,022.23
|
| Rate for Payer: Humana KY Medicaid |
$818.17
|
| Rate for Payer: Humana Medicare Advantage |
$47.80
|
| Rate for Payer: Kentucky WC Medicaid |
$826.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,950.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,755.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$834.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,093.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,784.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,903.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,069.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,641.57
|
| Rate for Payer: PHCS Commercial |
$2,283.93
|
| Rate for Payer: United Healthcare All Payer |
$2,093.60
|
|
|
GAMMAGARD 500mg(30gm) SDV
|
Facility
|
IP
|
$28,548.74
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,564.62 |
| Max. Negotiated Rate |
$27,406.79 |
| Rate for Payer: Aetna Commercial |
$21,982.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,268.02
|
| Rate for Payer: Cash Price |
$14,274.37
|
| Rate for Payer: Cigna Commercial |
$23,695.45
|
| Rate for Payer: First Health Commercial |
$27,121.30
|
| Rate for Payer: Humana Commercial |
$24,266.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,409.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,068.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,564.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,122.89
|
| Rate for Payer: Ohio Health Group HMO |
$21,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,838.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,837.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,698.63
|
| Rate for Payer: PHCS Commercial |
$27,406.79
|
| Rate for Payer: United Healthcare All Payer |
$25,122.89
|
|
|
GAMMAGARD 500mg(30gm) SDV
|
Facility
|
OP
|
$28,548.74
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$27,406.79 |
| Rate for Payer: Aetna Commercial |
$21,982.53
|
| Rate for Payer: Anthem Medicaid |
$9,817.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,268.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.53
|
| Rate for Payer: Cash Price |
$14,274.37
|
| Rate for Payer: Cash Price |
$14,274.37
|
| Rate for Payer: Cigna Commercial |
$23,695.45
|
| Rate for Payer: First Health Commercial |
$27,121.30
|
| Rate for Payer: Humana Commercial |
$24,266.43
|
| Rate for Payer: Humana KY Medicaid |
$9,817.91
|
| Rate for Payer: Humana Medicare Advantage |
$47.80
|
| Rate for Payer: Kentucky WC Medicaid |
$9,917.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,409.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,068.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,014.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,122.89
|
| Rate for Payer: Ohio Health Group HMO |
$21,411.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,838.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,837.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,698.63
|
| Rate for Payer: PHCS Commercial |
$27,406.79
|
| Rate for Payer: United Healthcare All Payer |
$25,122.89
|
|
|
GAMMAGARD 500mg(5gm) SDV
|
Facility
|
OP
|
$4,758.12
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$4,567.80 |
| Rate for Payer: Aetna Commercial |
$3,663.75
|
| Rate for Payer: Anthem Medicaid |
$1,636.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,711.33
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.53
|
| Rate for Payer: Cash Price |
$2,379.06
|
| Rate for Payer: Cash Price |
$2,379.06
|
| Rate for Payer: Cigna Commercial |
$3,949.24
|
| Rate for Payer: First Health Commercial |
$4,520.21
|
| Rate for Payer: Humana Commercial |
$4,044.40
|
| Rate for Payer: Humana KY Medicaid |
$1,636.32
|
| Rate for Payer: Humana Medicare Advantage |
$47.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,652.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,901.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,511.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,669.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,187.15
|
| Rate for Payer: Ohio Health Group HMO |
$3,568.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,806.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,139.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,283.10
|
| Rate for Payer: PHCS Commercial |
$4,567.80
|
| Rate for Payer: United Healthcare All Payer |
$4,187.15
|
|
|
GAMMAGARD 500mg(5gm) SDV
|
Facility
|
IP
|
$4,758.12
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,427.44 |
| Max. Negotiated Rate |
$4,567.80 |
| Rate for Payer: Aetna Commercial |
$3,663.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,711.33
|
| Rate for Payer: Cash Price |
$2,379.06
|
| Rate for Payer: Cigna Commercial |
$3,949.24
|
| Rate for Payer: First Health Commercial |
$4,520.21
|
| Rate for Payer: Humana Commercial |
$4,044.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,901.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,511.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,427.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,187.15
|
| Rate for Payer: Ohio Health Group HMO |
$3,568.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,806.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,139.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,283.10
|
| Rate for Payer: PHCS Commercial |
$4,567.80
|
| Rate for Payer: United Healthcare All Payer |
$4,187.15
|
|
|
GAMMAGARD SD 500mg(10gm) SDV
|
Facility
|
IP
|
$12,405.29
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,721.59 |
| Max. Negotiated Rate |
$11,909.08 |
| Rate for Payer: Aetna Commercial |
$9,552.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,676.13
|
| Rate for Payer: Cash Price |
$6,202.65
|
| Rate for Payer: Cigna Commercial |
$10,296.39
|
| Rate for Payer: First Health Commercial |
$11,785.03
|
| Rate for Payer: Humana Commercial |
$10,544.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,172.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,155.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,721.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,916.66
|
| Rate for Payer: Ohio Health Group HMO |
$9,303.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,924.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,792.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,559.65
|
| Rate for Payer: PHCS Commercial |
$11,909.08
|
| Rate for Payer: United Healthcare All Payer |
$10,916.66
|
|
|
GAMMAGARD SD 500mg(10gm) SDV
|
Facility
|
OP
|
$12,405.29
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.70 |
| Max. Negotiated Rate |
$11,909.08 |
| Rate for Payer: Aetna Commercial |
$9,552.07
|
| Rate for Payer: Anthem Medicaid |
$4,266.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,676.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$114.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.30
|
| Rate for Payer: Cash Price |
$6,202.65
|
| Rate for Payer: Cash Price |
$6,202.65
|
| Rate for Payer: Cigna Commercial |
$10,296.39
|
| Rate for Payer: First Health Commercial |
$11,785.03
|
| Rate for Payer: Humana Commercial |
$10,544.50
|
| Rate for Payer: Humana KY Medicaid |
$4,266.18
|
| Rate for Payer: Humana Medicare Advantage |
$81.70
|
| Rate for Payer: Kentucky WC Medicaid |
$4,309.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,172.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,155.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,351.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,916.66
|
| Rate for Payer: Ohio Health Group HMO |
$9,303.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,924.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,792.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,559.65
|
| Rate for Payer: PHCS Commercial |
$11,909.08
|
| Rate for Payer: United Healthcare All Payer |
$10,916.66
|
|
|
GAMMAGARD SD 500mg(5gm) SDV
|
Facility
|
OP
|
$6,202.65
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.70 |
| Max. Negotiated Rate |
$5,954.54 |
| Rate for Payer: Aetna Commercial |
$4,776.04
|
| Rate for Payer: Anthem Medicaid |
$2,133.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,838.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$114.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.30
|
| Rate for Payer: Cash Price |
$3,101.32
|
| Rate for Payer: Cash Price |
$3,101.32
|
| Rate for Payer: Cigna Commercial |
$5,148.20
|
| Rate for Payer: First Health Commercial |
$5,892.52
|
| Rate for Payer: Humana Commercial |
$5,272.25
|
| Rate for Payer: Humana KY Medicaid |
$2,133.09
|
| Rate for Payer: Humana Medicare Advantage |
$81.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,154.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,086.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,577.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,175.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,458.33
|
| Rate for Payer: Ohio Health Group HMO |
$4,651.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,962.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,396.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,279.83
|
| Rate for Payer: PHCS Commercial |
$5,954.54
|
| Rate for Payer: United Healthcare All Payer |
$5,458.33
|
|
|
GAMMAGARD SD 500mg(5gm) SDV
|
Facility
|
IP
|
$6,202.65
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,860.80 |
| Max. Negotiated Rate |
$5,954.54 |
| Rate for Payer: Aetna Commercial |
$4,776.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,838.07
|
| Rate for Payer: Cash Price |
$3,101.32
|
| Rate for Payer: Cigna Commercial |
$5,148.20
|
| Rate for Payer: First Health Commercial |
$5,892.52
|
| Rate for Payer: Humana Commercial |
$5,272.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,086.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,577.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,860.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,458.33
|
| Rate for Payer: Ohio Health Group HMO |
$4,651.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,962.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,396.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,279.83
|
| Rate for Payer: PHCS Commercial |
$5,954.54
|
| Rate for Payer: United Healthcare All Payer |
$5,458.33
|
|
