|
GAMUNEX C 500mg (10gm) SDV
|
Facility
|
OP
|
$8,106.33
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003833
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$7,782.08 |
| Rate for Payer: Aetna Commercial |
$6,241.87
|
| Rate for Payer: Anthem Medicaid |
$2,787.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,322.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.84
|
| Rate for Payer: Cash Price |
$4,053.16
|
| Rate for Payer: Cash Price |
$4,053.16
|
| Rate for Payer: Cigna Commercial |
$6,728.25
|
| Rate for Payer: First Health Commercial |
$7,701.01
|
| Rate for Payer: Humana Commercial |
$6,890.38
|
| Rate for Payer: Humana KY Medicaid |
$2,787.77
|
| Rate for Payer: Humana Medicare Advantage |
$48.03
|
| Rate for Payer: Kentucky WC Medicaid |
$2,816.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,647.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,982.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,843.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$6,079.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,485.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,052.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,593.37
|
| Rate for Payer: PHCS Commercial |
$7,782.08
|
| Rate for Payer: United Healthcare All Payer |
$7,133.57
|
|
|
GAMUNEX C 500mg (10gm) SDV
|
Facility
|
IP
|
$8,106.33
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003833
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,431.90 |
| Max. Negotiated Rate |
$7,782.08 |
| Rate for Payer: Aetna Commercial |
$6,241.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,322.94
|
| Rate for Payer: Cash Price |
$4,053.16
|
| Rate for Payer: Cigna Commercial |
$6,728.25
|
| Rate for Payer: First Health Commercial |
$7,701.01
|
| Rate for Payer: Humana Commercial |
$6,890.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,647.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,982.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,431.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$6,079.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,485.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,052.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,593.37
|
| Rate for Payer: PHCS Commercial |
$7,782.08
|
| Rate for Payer: United Healthcare All Payer |
$7,133.57
|
|
|
GAMUNEX C 500mg (1gm) SDV
|
Facility
|
OP
|
$810.63
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$778.20 |
| Rate for Payer: Aetna Commercial |
$624.19
|
| Rate for Payer: Anthem Medicaid |
$278.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$632.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.84
|
| Rate for Payer: Cash Price |
$405.32
|
| Rate for Payer: Cash Price |
$405.32
|
| Rate for Payer: Cigna Commercial |
$672.82
|
| Rate for Payer: First Health Commercial |
$770.10
|
| Rate for Payer: Humana Commercial |
$689.04
|
| Rate for Payer: Humana KY Medicaid |
$278.78
|
| Rate for Payer: Humana Medicare Advantage |
$48.03
|
| Rate for Payer: Kentucky WC Medicaid |
$281.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$598.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$713.35
|
| Rate for Payer: Ohio Health Group HMO |
$607.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$705.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.33
|
| Rate for Payer: PHCS Commercial |
$778.20
|
| Rate for Payer: United Healthcare All Payer |
$713.35
|
|
|
GAMUNEX C 500mg (1gm) SDV
|
Facility
|
IP
|
$810.63
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.19 |
| Max. Negotiated Rate |
$778.20 |
| Rate for Payer: Aetna Commercial |
$624.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$632.29
|
| Rate for Payer: Cash Price |
$405.32
|
| Rate for Payer: Cigna Commercial |
$672.82
|
| Rate for Payer: First Health Commercial |
$770.10
|
| Rate for Payer: Humana Commercial |
$689.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$598.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$713.35
|
| Rate for Payer: Ohio Health Group HMO |
$607.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$705.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.33
|
| Rate for Payer: PHCS Commercial |
$778.20
|
| Rate for Payer: United Healthcare All Payer |
$713.35
|
|
|
GAMUNEX C 500mg (20gm) SDV
|
Facility
|
IP
|
$16,212.66
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,863.80 |
| Max. Negotiated Rate |
$15,564.15 |
| Rate for Payer: Aetna Commercial |
$12,483.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,645.87
|
| Rate for Payer: Cash Price |
$8,106.33
|
| Rate for Payer: Cigna Commercial |
$13,456.51
|
| Rate for Payer: First Health Commercial |
$15,402.03
|
| Rate for Payer: Humana Commercial |
$13,780.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,294.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,964.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,863.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,267.14
|
| Rate for Payer: Ohio Health Group HMO |
$12,159.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,970.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,105.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,186.74
|
| Rate for Payer: PHCS Commercial |
$15,564.15
|
| Rate for Payer: United Healthcare All Payer |
$14,267.14
|
|
|
GAMUNEX C 500mg (20gm) SDV
|
Facility
|
OP
|
$16,212.66
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$15,564.15 |
| Rate for Payer: Aetna Commercial |
$12,483.75
|
| Rate for Payer: Anthem Medicaid |
$5,575.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,645.87
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.84
|
| Rate for Payer: Cash Price |
$8,106.33
|
| Rate for Payer: Cash Price |
$8,106.33
|
| Rate for Payer: Cigna Commercial |
$13,456.51
|
| Rate for Payer: First Health Commercial |
$15,402.03
|
| Rate for Payer: Humana Commercial |
$13,780.76
|
| Rate for Payer: Humana KY Medicaid |
$5,575.53
|
| Rate for Payer: Humana Medicare Advantage |
$48.03
|
| Rate for Payer: Kentucky WC Medicaid |
$5,632.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,294.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,964.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,687.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,267.14
|
| Rate for Payer: Ohio Health Group HMO |
$12,159.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,970.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,105.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,186.74
|
| Rate for Payer: PHCS Commercial |
$15,564.15
|
| Rate for Payer: United Healthcare All Payer |
$14,267.14
|
|
|
GAMUNEX C 500mg (2.5gm) SDV
|
Facility
|
OP
|
$2,026.58
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$1,945.52 |
| Rate for Payer: Aetna Commercial |
$1,560.47
|
| Rate for Payer: Anthem Medicaid |
$696.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.84
|
| Rate for Payer: Cash Price |
$1,013.29
|
| Rate for Payer: Cash Price |
$1,013.29
|
| Rate for Payer: Cigna Commercial |
$1,682.06
|
| Rate for Payer: First Health Commercial |
$1,925.25
|
| Rate for Payer: Humana Commercial |
$1,722.59
|
| Rate for Payer: Humana KY Medicaid |
$696.94
|
| Rate for Payer: Humana Medicare Advantage |
$48.03
|
| Rate for Payer: Kentucky WC Medicaid |
$704.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,783.39
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,621.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,763.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,398.34
|
| Rate for Payer: PHCS Commercial |
$1,945.52
|
| Rate for Payer: United Healthcare All Payer |
$1,783.39
|
|
|
GAMUNEX C 500mg (2.5gm) SDV
|
Facility
|
IP
|
$2,026.58
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$607.97 |
| Max. Negotiated Rate |
$1,945.52 |
| Rate for Payer: Aetna Commercial |
$1,560.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.73
|
| Rate for Payer: Cash Price |
$1,013.29
|
| Rate for Payer: Cigna Commercial |
$1,682.06
|
| Rate for Payer: First Health Commercial |
$1,925.25
|
| Rate for Payer: Humana Commercial |
$1,722.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,783.39
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,621.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,763.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,398.34
|
| Rate for Payer: PHCS Commercial |
$1,945.52
|
| Rate for Payer: United Healthcare All Payer |
$1,783.39
|
|
|
GAMUNEX C 500mg (40gm) SDV
|
Facility
|
IP
|
$32,425.32
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,727.60 |
| Max. Negotiated Rate |
$31,128.31 |
| Rate for Payer: Aetna Commercial |
$24,967.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,291.75
|
| Rate for Payer: Cash Price |
$16,212.66
|
| Rate for Payer: Cigna Commercial |
$26,913.02
|
| Rate for Payer: First Health Commercial |
$30,804.05
|
| Rate for Payer: Humana Commercial |
$27,561.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,588.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,929.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,727.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,534.28
|
| Rate for Payer: Ohio Health Group HMO |
$24,318.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,940.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,210.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,373.47
|
| Rate for Payer: PHCS Commercial |
$31,128.31
|
| Rate for Payer: United Healthcare All Payer |
$28,534.28
|
|
|
GAMUNEX C 500mg (40gm) SDV
|
Facility
|
OP
|
$32,425.32
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$31,128.31 |
| Rate for Payer: Aetna Commercial |
$24,967.50
|
| Rate for Payer: Anthem Medicaid |
$11,151.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,291.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.84
|
| Rate for Payer: Cash Price |
$16,212.66
|
| Rate for Payer: Cash Price |
$16,212.66
|
| Rate for Payer: Cigna Commercial |
$26,913.02
|
| Rate for Payer: First Health Commercial |
$30,804.05
|
| Rate for Payer: Humana Commercial |
$27,561.52
|
| Rate for Payer: Humana KY Medicaid |
$11,151.07
|
| Rate for Payer: Humana Medicare Advantage |
$48.03
|
| Rate for Payer: Kentucky WC Medicaid |
$11,264.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,588.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,929.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,374.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,534.28
|
| Rate for Payer: Ohio Health Group HMO |
$24,318.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,940.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,210.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,373.47
|
| Rate for Payer: PHCS Commercial |
$31,128.31
|
| Rate for Payer: United Healthcare All Payer |
$28,534.28
|
|
|
GAMUNEX C 500mg (5gm) SDV
|
Facility
|
IP
|
$4,053.17
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,215.95 |
| Max. Negotiated Rate |
$3,891.04 |
| Rate for Payer: Aetna Commercial |
$3,120.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,161.47
|
| Rate for Payer: Cash Price |
$2,026.59
|
| Rate for Payer: Cigna Commercial |
$3,364.13
|
| Rate for Payer: First Health Commercial |
$3,850.51
|
| Rate for Payer: Humana Commercial |
$3,445.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,323.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,991.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,215.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,566.79
|
| Rate for Payer: Ohio Health Group HMO |
$3,039.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,242.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,526.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.69
|
| Rate for Payer: PHCS Commercial |
$3,891.04
|
| Rate for Payer: United Healthcare All Payer |
$3,566.79
|
|
|
GAMUNEX C 500mg (5gm) SDV
|
Facility
|
OP
|
$4,053.17
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$3,891.04 |
| Rate for Payer: Aetna Commercial |
$3,120.94
|
| Rate for Payer: Anthem Medicaid |
$1,393.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,161.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.84
|
| Rate for Payer: Cash Price |
$2,026.59
|
| Rate for Payer: Cash Price |
$2,026.59
|
| Rate for Payer: Cigna Commercial |
$3,364.13
|
| Rate for Payer: First Health Commercial |
$3,850.51
|
| Rate for Payer: Humana Commercial |
$3,445.19
|
| Rate for Payer: Humana KY Medicaid |
$1,393.89
|
| Rate for Payer: Humana Medicare Advantage |
$48.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1,408.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,323.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,991.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,421.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,566.79
|
| Rate for Payer: Ohio Health Group HMO |
$3,039.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,242.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,526.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.69
|
| Rate for Payer: PHCS Commercial |
$3,891.04
|
| Rate for Payer: United Healthcare All Payer |
$3,566.79
|
|
|
GARAMYCIN(GENTAMICIN)0.1% 15GM
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 713068215
|
| Hospital Charge Code |
25000711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$12.19 |
| Rate for Payer: Aetna Commercial |
$9.78
|
| Rate for Payer: Anthem Medicaid |
$4.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.91
|
| Rate for Payer: Cash Price |
$6.35
|
| Rate for Payer: Cigna Commercial |
$10.54
|
| Rate for Payer: First Health Commercial |
$12.06
|
| Rate for Payer: Humana Commercial |
$10.79
|
| Rate for Payer: Humana KY Medicaid |
$4.37
|
| Rate for Payer: Kentucky WC Medicaid |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.18
|
| Rate for Payer: Ohio Health Group HMO |
$9.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.76
|
| Rate for Payer: PHCS Commercial |
$12.19
|
| Rate for Payer: United Healthcare All Payer |
$11.18
|
|
|
GARAMYCIN(GENTAMICIN)0.1% 15GM
|
Facility
|
IP
|
$12.70
|
|
|
Service Code
|
NDC 713068215
|
| Hospital Charge Code |
25000711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$12.19 |
| Rate for Payer: Aetna Commercial |
$9.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.91
|
| Rate for Payer: Cash Price |
$6.35
|
| Rate for Payer: Cigna Commercial |
$10.54
|
| Rate for Payer: First Health Commercial |
$12.06
|
| Rate for Payer: Humana Commercial |
$10.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.18
|
| Rate for Payer: Ohio Health Group HMO |
$9.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.76
|
| Rate for Payer: PHCS Commercial |
$12.19
|
| Rate for Payer: United Healthcare All Payer |
$11.18
|
|
|
GARAMYCIN(GENTAMICIN) OPH 5ML
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
25000710
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.55
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
GARAMYCIN(GENTAMICIN) OPH 5ML
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
25000710
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem Medicaid |
$0.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Humana KY Medicaid |
$0.28
|
| Rate for Payer: Kentucky WC Medicaid |
$0.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.55
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
GARDNERELLA VAGINALIS PCR
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS 87511
|
| Hospital Charge Code |
30001374
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$144.96 |
| Rate for Payer: Aetna Commercial |
$116.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.25
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$125.33
|
| Rate for Payer: First Health Commercial |
$143.45
|
| Rate for Payer: Humana Commercial |
$128.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.88
|
| Rate for Payer: Ohio Health Group HMO |
$113.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.19
|
| Rate for Payer: PHCS Commercial |
$144.96
|
| Rate for Payer: United Healthcare All Payer |
$132.88
|
|
|
GARDNERELLA VAGINALIS PCR
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
HCPCS 87511
|
| Hospital Charge Code |
30001374
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$90.60 |
| Rate for Payer: Aetna Commercial |
$45.85
|
| Rate for Payer: Ambetter Exchange |
$35.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.11
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$30.93
|
| Rate for Payer: Healthspan PPO |
$36.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.09
|
| Rate for Payer: Multiplan PHCS |
$90.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.62
|
| Rate for Payer: UHCCP Medicaid |
$52.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.09
|
|
|
GARDNERELLA VAGINALIS PCR
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS 87511
|
| Hospital Charge Code |
30001374
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$144.96 |
| Rate for Payer: Aetna Commercial |
$116.27
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$125.33
|
| Rate for Payer: First Health Commercial |
$143.45
|
| Rate for Payer: Humana Commercial |
$128.35
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.88
|
| Rate for Payer: Ohio Health Group HMO |
$113.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.19
|
| Rate for Payer: PHCS Commercial |
$144.96
|
| Rate for Payer: United Healthcare All Payer |
$132.88
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
46000013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$82.80 |
| Max. Negotiated Rate |
$264.96 |
| Rate for Payer: Aetna Commercial |
$212.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$215.28
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$229.08
|
| Rate for Payer: First Health Commercial |
$262.20
|
| Rate for Payer: Humana Commercial |
$234.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$226.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$203.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.88
|
| Rate for Payer: Ohio Health Group HMO |
$207.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$190.44
|
| Rate for Payer: PHCS Commercial |
$264.96
|
| Rate for Payer: United Healthcare All Payer |
$242.88
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Professional
|
Both
|
$44.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
460P0013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$15.10 |
| Max. Negotiated Rate |
$69.47 |
| Rate for Payer: Ambetter Exchange |
$40.61
|
| Rate for Payer: Anthem Medicaid |
$32.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$40.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.73
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cigna Commercial |
$69.47
|
| Rate for Payer: Healthspan PPO |
$35.92
|
| Rate for Payer: Humana Medicaid |
$32.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$40.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.41
|
| Rate for Payer: Molina Healthcare Passport |
$32.75
|
| Rate for Payer: Multiplan PHCS |
$26.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.79
|
| Rate for Payer: UHCCP Medicaid |
$15.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$40.61
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
460T0013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$69.60 |
| Max. Negotiated Rate |
$222.72 |
| Rate for Payer: Aetna Commercial |
$178.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.96
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cigna Commercial |
$192.56
|
| Rate for Payer: First Health Commercial |
$220.40
|
| Rate for Payer: Humana Commercial |
$197.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$190.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$171.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$204.16
|
| Rate for Payer: Ohio Health Group HMO |
$174.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$185.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.08
|
| Rate for Payer: PHCS Commercial |
$222.72
|
| Rate for Payer: United Healthcare All Payer |
$204.16
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
46000013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$94.92 |
| Max. Negotiated Rate |
$264.96 |
| Rate for Payer: Aetna Commercial |
$212.52
|
| Rate for Payer: Anthem Medicaid |
$94.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$215.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$229.08
|
| Rate for Payer: First Health Commercial |
$262.20
|
| Rate for Payer: Humana Commercial |
$234.60
|
| Rate for Payer: Humana KY Medicaid |
$94.92
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$95.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$226.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$203.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$96.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.88
|
| Rate for Payer: Ohio Health Group HMO |
$207.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$190.44
|
| Rate for Payer: PHCS Commercial |
$264.96
|
| Rate for Payer: United Healthcare All Payer |
$242.88
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
460T0013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$79.78 |
| Max. Negotiated Rate |
$222.72 |
| Rate for Payer: Aetna Commercial |
$178.64
|
| Rate for Payer: Anthem Medicaid |
$79.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cigna Commercial |
$192.56
|
| Rate for Payer: First Health Commercial |
$220.40
|
| Rate for Payer: Humana Commercial |
$197.20
|
| Rate for Payer: Humana KY Medicaid |
$79.78
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$80.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$190.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$171.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$81.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$204.16
|
| Rate for Payer: Ohio Health Group HMO |
$174.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$185.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.08
|
| Rate for Payer: PHCS Commercial |
$222.72
|
| Rate for Payer: United Healthcare All Payer |
$204.16
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Professional
|
Both
|
$276.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
46000013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$15.10 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Ambetter Exchange |
$40.61
|
| Rate for Payer: Anthem Medicaid |
$32.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$40.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.73
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$69.47
|
| Rate for Payer: Healthspan PPO |
$35.92
|
| Rate for Payer: Humana Medicaid |
$32.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$40.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.41
|
| Rate for Payer: Molina Healthcare Passport |
$32.75
|
| Rate for Payer: Multiplan PHCS |
$165.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.79
|
| Rate for Payer: UHCCP Medicaid |
$96.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$40.61
|
|
