|
GAMASTAN VIAL (2ML)
|
Facility
|
IP
|
$532.04
|
|
|
Service Code
|
HCPCS J1460
|
| Hospital Charge Code |
25002079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.17 |
| 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 |
$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
|
|
|
GAMMA-BSM KIT 10CC
|
Facility
|
IP
|
$22,174.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,882.62 |
| Max. Negotiated Rate |
$21,287.04 |
| Rate for Payer: Aetna Commercial |
$17,073.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,295.72
|
| Rate for Payer: Cash Price |
$11,087.00
|
| Rate for Payer: Cigna Commercial |
$18,404.42
|
| Rate for Payer: First Health Commercial |
$21,065.30
|
| Rate for Payer: Humana Commercial |
$18,847.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,182.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,364.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,652.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,513.12
|
| Rate for Payer: Ohio Health Group HMO |
$16,630.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,434.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,882.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,873.94
|
| Rate for Payer: PHCS Commercial |
$21,287.04
|
| Rate for Payer: United Healthcare All Payer |
$19,513.12
|
|
|
GAMMA-BSM KIT 10CC
|
Facility
|
OP
|
$22,174.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,882.62 |
| Max. Negotiated Rate |
$21,287.04 |
| Rate for Payer: Aetna Commercial |
$17,073.98
|
| Rate for Payer: Anthem Medicaid |
$7,625.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,295.72
|
| Rate for Payer: Cash Price |
$11,087.00
|
| Rate for Payer: Cigna Commercial |
$18,404.42
|
| Rate for Payer: First Health Commercial |
$21,065.30
|
| Rate for Payer: Humana Commercial |
$18,847.90
|
| Rate for Payer: Humana KY Medicaid |
$7,625.64
|
| Rate for Payer: Kentucky WC Medicaid |
$7,703.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,182.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,364.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,652.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,778.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,513.12
|
| Rate for Payer: Ohio Health Group HMO |
$16,630.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,434.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,882.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,873.94
|
| Rate for Payer: PHCS Commercial |
$21,287.04
|
| Rate for Payer: United Healthcare All Payer |
$19,513.12
|
|
|
GAMMA- BSM KIT 2.5CC
|
Facility
|
OP
|
$11,154.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.12 |
| Max. Negotiated Rate |
$10,708.61 |
| Rate for Payer: Aetna Commercial |
$8,589.20
|
| Rate for Payer: Anthem Medicaid |
$3,836.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,700.74
|
| Rate for Payer: Cash Price |
$5,577.40
|
| Rate for Payer: Cigna Commercial |
$9,258.48
|
| Rate for Payer: First Health Commercial |
$10,597.06
|
| Rate for Payer: Humana Commercial |
$9,481.58
|
| Rate for Payer: Humana KY Medicaid |
$3,836.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,875.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,146.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,232.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,346.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,913.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,816.22
|
| Rate for Payer: Ohio Health Group HMO |
$8,366.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,230.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,450.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,457.99
|
| Rate for Payer: PHCS Commercial |
$10,708.61
|
| Rate for Payer: United Healthcare All Payer |
$9,816.22
|
|
|
GAMMA- BSM KIT 2.5CC
|
Facility
|
IP
|
$11,154.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.12 |
| Max. Negotiated Rate |
$10,708.61 |
| Rate for Payer: Aetna Commercial |
$8,589.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,700.74
|
| Rate for Payer: Cash Price |
$5,577.40
|
| Rate for Payer: Cigna Commercial |
$9,258.48
|
| Rate for Payer: First Health Commercial |
$10,597.06
|
| Rate for Payer: Humana Commercial |
$9,481.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,146.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,232.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,346.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,816.22
|
| Rate for Payer: Ohio Health Group HMO |
$8,366.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,230.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,450.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,457.99
|
| Rate for Payer: PHCS Commercial |
$10,708.61
|
| Rate for Payer: United Healthcare All Payer |
$9,816.22
|
|
|
GAMMA-BSM KIT 5CC
|
Facility
|
IP
|
$15,403.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.42 |
| Max. Negotiated Rate |
$14,787.07 |
| Rate for Payer: Aetna Commercial |
$11,860.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,014.50
|
| Rate for Payer: Cash Price |
$7,701.60
|
| Rate for Payer: Cigna Commercial |
$12,784.66
|
| Rate for Payer: First Health Commercial |
$14,633.04
|
| Rate for Payer: Humana Commercial |
$13,092.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,630.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,367.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,620.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,554.82
|
| Rate for Payer: Ohio Health Group HMO |
$11,552.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,080.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,774.99
|
| Rate for Payer: PHCS Commercial |
$14,787.07
|
| Rate for Payer: United Healthcare All Payer |
$13,554.82
|
|
|
GAMMA-BSM KIT 5CC
|
Facility
|
OP
|
$15,403.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.42 |
| Max. Negotiated Rate |
$14,787.07 |
| Rate for Payer: Aetna Commercial |
$11,860.46
|
| Rate for Payer: Anthem Medicaid |
$5,297.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,014.50
|
| Rate for Payer: Cash Price |
$7,701.60
|
| Rate for Payer: Cigna Commercial |
$12,784.66
|
| Rate for Payer: First Health Commercial |
$14,633.04
|
| Rate for Payer: Humana Commercial |
$13,092.72
|
| Rate for Payer: Humana KY Medicaid |
$5,297.16
|
| Rate for Payer: Kentucky WC Medicaid |
$5,351.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,630.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,367.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,620.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,403.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,554.82
|
| Rate for Payer: Ohio Health Group HMO |
$11,552.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,080.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,774.99
|
| Rate for Payer: PHCS Commercial |
$14,787.07
|
| Rate for Payer: United Healthcare All Payer |
$13,554.82
|
|
|
GAMMAGARD 500mg(10gm) SDV
|
Facility
|
IP
|
$9,238.84
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,201.05 |
| Max. Negotiated Rate |
$8,869.29 |
| Rate for Payer: Aetna Commercial |
$7,113.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,206.30
|
| Rate for Payer: Cash Price |
$4,619.42
|
| Rate for Payer: Cigna Commercial |
$7,668.24
|
| Rate for Payer: First Health Commercial |
$8,776.90
|
| Rate for Payer: Humana Commercial |
$7,853.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,575.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,818.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,771.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,130.18
|
| Rate for Payer: Ohio Health Group HMO |
$6,929.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,847.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,201.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,864.04
|
| Rate for Payer: PHCS Commercial |
$8,869.29
|
| Rate for Payer: United Healthcare All Payer |
$8,130.18
|
|
|
GAMMAGARD 500mg(10gm) SDV
|
Facility
|
OP
|
$9,238.84
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$8,869.29 |
| Rate for Payer: Aetna Commercial |
$7,113.91
|
| Rate for Payer: Anthem Medicaid |
$3,177.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,206.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.61
|
| Rate for Payer: Cash Price |
$4,619.42
|
| Rate for Payer: Cash Price |
$4,619.42
|
| Rate for Payer: Cigna Commercial |
$7,668.24
|
| Rate for Payer: First Health Commercial |
$8,776.90
|
| Rate for Payer: Humana Commercial |
$7,853.01
|
| Rate for Payer: Humana KY Medicaid |
$3,177.24
|
| Rate for Payer: Humana Medicare Advantage |
$44.15
|
| Rate for Payer: Kentucky WC Medicaid |
$3,209.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,575.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,818.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,240.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,130.18
|
| Rate for Payer: Ohio Health Group HMO |
$6,929.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,847.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,201.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,864.04
|
| Rate for Payer: PHCS Commercial |
$8,869.29
|
| Rate for Payer: United Healthcare All Payer |
$8,130.18
|
|
|
GAMMAGARD 500mg(1gm) SDV
|
Facility
|
IP
|
$923.88
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25003837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.10 |
| Max. Negotiated Rate |
$886.92 |
| Rate for Payer: Aetna Commercial |
$711.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$720.63
|
| Rate for Payer: Cash Price |
$461.94
|
| Rate for Payer: Cigna Commercial |
$766.82
|
| Rate for Payer: First Health Commercial |
$877.69
|
| Rate for Payer: Humana Commercial |
$785.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$757.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$681.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$277.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$813.01
|
| Rate for Payer: Ohio Health Group HMO |
$692.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$286.40
|
| Rate for Payer: PHCS Commercial |
$886.92
|
| Rate for Payer: United Healthcare All Payer |
$813.01
|
|
|
GAMMAGARD 500mg(1gm) SDV
|
Facility
|
OP
|
$923.88
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25003837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$886.92 |
| Rate for Payer: Aetna Commercial |
$711.39
|
| Rate for Payer: Anthem Medicaid |
$317.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$720.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.61
|
| Rate for Payer: Cash Price |
$461.94
|
| Rate for Payer: Cash Price |
$461.94
|
| Rate for Payer: Cigna Commercial |
$766.82
|
| Rate for Payer: First Health Commercial |
$877.69
|
| Rate for Payer: Humana Commercial |
$785.30
|
| Rate for Payer: Humana KY Medicaid |
$317.72
|
| Rate for Payer: Humana Medicare Advantage |
$44.15
|
| Rate for Payer: Kentucky WC Medicaid |
$320.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$757.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$681.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$324.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$813.01
|
| Rate for Payer: Ohio Health Group HMO |
$692.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$184.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$286.40
|
| Rate for Payer: PHCS Commercial |
$886.92
|
| Rate for Payer: United Healthcare All Payer |
$813.01
|
|
|
GAMMAGARD 500mg(20gm) SDV
|
Facility
|
IP
|
$18,477.68
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,402.10 |
| Max. Negotiated Rate |
$17,738.57 |
| Rate for Payer: Aetna Commercial |
$14,227.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,412.59
|
| Rate for Payer: Cash Price |
$9,238.84
|
| Rate for Payer: Cigna Commercial |
$15,336.47
|
| Rate for Payer: First Health Commercial |
$17,553.80
|
| Rate for Payer: Humana Commercial |
$15,706.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,151.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,636.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,543.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,260.36
|
| Rate for Payer: Ohio Health Group HMO |
$13,858.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,695.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,402.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,728.08
|
| Rate for Payer: PHCS Commercial |
$17,738.57
|
| Rate for Payer: United Healthcare All Payer |
$16,260.36
|
|
|
GAMMAGARD 500mg(20gm) SDV
|
Facility
|
OP
|
$18,477.68
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$17,738.57 |
| Rate for Payer: Aetna Commercial |
$14,227.81
|
| Rate for Payer: Anthem Medicaid |
$6,354.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,412.59
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.61
|
| Rate for Payer: Cash Price |
$9,238.84
|
| Rate for Payer: Cash Price |
$9,238.84
|
| Rate for Payer: Cigna Commercial |
$15,336.47
|
| Rate for Payer: First Health Commercial |
$17,553.80
|
| Rate for Payer: Humana Commercial |
$15,706.03
|
| Rate for Payer: Humana KY Medicaid |
$6,354.47
|
| Rate for Payer: Humana Medicare Advantage |
$44.15
|
| Rate for Payer: Kentucky WC Medicaid |
$6,419.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,151.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,636.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,481.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,260.36
|
| Rate for Payer: Ohio Health Group HMO |
$13,858.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,695.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,402.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,728.08
|
| Rate for Payer: PHCS Commercial |
$17,738.57
|
| Rate for Payer: United Healthcare All Payer |
$16,260.36
|
|
|
GAMMAGARD 500mg(2.5gm) SDV
|
Facility
|
IP
|
$2,309.71
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$300.26 |
| Max. Negotiated Rate |
$2,217.32 |
| Rate for Payer: Aetna Commercial |
$1,778.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,801.57
|
| Rate for Payer: Cash Price |
$1,154.86
|
| Rate for Payer: Cigna Commercial |
$1,917.06
|
| Rate for Payer: First Health Commercial |
$2,194.22
|
| Rate for Payer: Humana Commercial |
$1,963.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,893.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,704.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$692.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,032.54
|
| Rate for Payer: Ohio Health Group HMO |
$1,732.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$461.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$300.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$716.01
|
| Rate for Payer: PHCS Commercial |
$2,217.32
|
| Rate for Payer: United Healthcare All Payer |
$2,032.54
|
|
|
GAMMAGARD 500mg(2.5gm) SDV
|
Facility
|
OP
|
$2,309.71
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$2,217.32 |
| Rate for Payer: Aetna Commercial |
$1,778.48
|
| Rate for Payer: Anthem Medicaid |
$794.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,801.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.61
|
| Rate for Payer: Cash Price |
$1,154.86
|
| Rate for Payer: Cash Price |
$1,154.86
|
| Rate for Payer: Cigna Commercial |
$1,917.06
|
| Rate for Payer: First Health Commercial |
$2,194.22
|
| Rate for Payer: Humana Commercial |
$1,963.25
|
| Rate for Payer: Humana KY Medicaid |
$794.31
|
| Rate for Payer: Humana Medicare Advantage |
$44.15
|
| Rate for Payer: Kentucky WC Medicaid |
$802.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,893.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,704.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$810.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,032.54
|
| Rate for Payer: Ohio Health Group HMO |
$1,732.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$461.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$300.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$716.01
|
| Rate for Payer: PHCS Commercial |
$2,217.32
|
| Rate for Payer: United Healthcare All Payer |
$2,032.54
|
|
|
GAMMAGARD 500mg(30gm) SDV
|
Facility
|
IP
|
$27,716.52
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,603.15 |
| Max. Negotiated Rate |
$26,607.86 |
| Rate for Payer: Aetna Commercial |
$21,341.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,618.89
|
| Rate for Payer: Cash Price |
$13,858.26
|
| Rate for Payer: Cigna Commercial |
$23,004.71
|
| Rate for Payer: First Health Commercial |
$26,330.69
|
| Rate for Payer: Humana Commercial |
$23,559.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,727.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,454.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,314.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,390.54
|
| Rate for Payer: Ohio Health Group HMO |
$20,787.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,543.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,603.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,592.12
|
| Rate for Payer: PHCS Commercial |
$26,607.86
|
| Rate for Payer: United Healthcare All Payer |
$24,390.54
|
|
|
GAMMAGARD 500mg(30gm) SDV
|
Facility
|
OP
|
$27,716.52
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$26,607.86 |
| Rate for Payer: Aetna Commercial |
$21,341.72
|
| Rate for Payer: Anthem Medicaid |
$9,531.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,618.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.61
|
| Rate for Payer: Cash Price |
$13,858.26
|
| Rate for Payer: Cash Price |
$13,858.26
|
| Rate for Payer: Cigna Commercial |
$23,004.71
|
| Rate for Payer: First Health Commercial |
$26,330.69
|
| Rate for Payer: Humana Commercial |
$23,559.04
|
| Rate for Payer: Humana KY Medicaid |
$9,531.71
|
| Rate for Payer: Humana Medicare Advantage |
$44.15
|
| Rate for Payer: Kentucky WC Medicaid |
$9,628.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,727.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,454.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,722.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,390.54
|
| Rate for Payer: Ohio Health Group HMO |
$20,787.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,543.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,603.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,592.12
|
| Rate for Payer: PHCS Commercial |
$26,607.86
|
| Rate for Payer: United Healthcare All Payer |
$24,390.54
|
|
|
GAMMAGARD 500mg(5gm) SDV
|
Facility
|
OP
|
$4,619.42
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$4,434.64 |
| Rate for Payer: Aetna Commercial |
$3,556.95
|
| Rate for Payer: Anthem Medicaid |
$1,588.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,603.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$61.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.61
|
| Rate for Payer: Cash Price |
$2,309.71
|
| Rate for Payer: Cash Price |
$2,309.71
|
| Rate for Payer: Cigna Commercial |
$3,834.12
|
| Rate for Payer: First Health Commercial |
$4,388.45
|
| Rate for Payer: Humana Commercial |
$3,926.51
|
| Rate for Payer: Humana KY Medicaid |
$1,588.62
|
| Rate for Payer: Humana Medicare Advantage |
$44.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1,604.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,787.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,409.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,620.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,065.09
|
| Rate for Payer: Ohio Health Group HMO |
$3,464.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$923.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$600.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,432.02
|
| Rate for Payer: PHCS Commercial |
$4,434.64
|
| Rate for Payer: United Healthcare All Payer |
$4,065.09
|
|
|
GAMMAGARD 500mg(5gm) SDV
|
Facility
|
IP
|
$4,619.42
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
25002094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$600.52 |
| Max. Negotiated Rate |
$4,434.64 |
| Rate for Payer: Aetna Commercial |
$3,556.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,603.15
|
| Rate for Payer: Cash Price |
$2,309.71
|
| Rate for Payer: Cigna Commercial |
$3,834.12
|
| Rate for Payer: First Health Commercial |
$4,388.45
|
| Rate for Payer: Humana Commercial |
$3,926.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,787.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,409.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,385.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,065.09
|
| Rate for Payer: Ohio Health Group HMO |
$3,464.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$923.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$600.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,432.02
|
| Rate for Payer: PHCS Commercial |
$4,434.64
|
| Rate for Payer: United Healthcare All Payer |
$4,065.09
|
|
|
GAMMAGARD SD 500mg(10gm) SDV
|
Facility
|
IP
|
$12,222.17
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,588.88 |
| Max. Negotiated Rate |
$11,733.28 |
| Rate for Payer: Aetna Commercial |
$9,411.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,533.29
|
| Rate for Payer: Cash Price |
$6,111.08
|
| Rate for Payer: Cigna Commercial |
$10,144.40
|
| Rate for Payer: First Health Commercial |
$11,611.06
|
| Rate for Payer: Humana Commercial |
$10,388.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,022.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,019.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,666.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,755.51
|
| Rate for Payer: Ohio Health Group HMO |
$9,166.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,444.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,588.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,788.87
|
| Rate for Payer: PHCS Commercial |
$11,733.28
|
| Rate for Payer: United Healthcare All Payer |
$10,755.51
|
|
|
GAMMAGARD SD 500mg(10gm) SDV
|
Facility
|
OP
|
$12,222.17
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.50 |
| Max. Negotiated Rate |
$11,733.28 |
| Rate for Payer: Aetna Commercial |
$9,411.07
|
| Rate for Payer: Anthem Medicaid |
$4,203.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,533.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$109.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.98
|
| Rate for Payer: Cash Price |
$6,111.08
|
| Rate for Payer: Cash Price |
$6,111.08
|
| Rate for Payer: Cigna Commercial |
$10,144.40
|
| Rate for Payer: First Health Commercial |
$11,611.06
|
| Rate for Payer: Humana Commercial |
$10,388.84
|
| Rate for Payer: Humana KY Medicaid |
$4,203.20
|
| Rate for Payer: Humana Medicare Advantage |
$78.50
|
| Rate for Payer: Kentucky WC Medicaid |
$4,245.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,022.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,019.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,287.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,755.51
|
| Rate for Payer: Ohio Health Group HMO |
$9,166.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,444.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,588.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,788.87
|
| Rate for Payer: PHCS Commercial |
$11,733.28
|
| Rate for Payer: United Healthcare All Payer |
$10,755.51
|
|
|
GAMMAGARD SD 500mg(5gm) SDV
|
Facility
|
IP
|
$6,111.09
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$794.44 |
| Max. Negotiated Rate |
$5,866.65 |
| Rate for Payer: Aetna Commercial |
$4,705.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,766.65
|
| Rate for Payer: Cash Price |
$3,055.54
|
| Rate for Payer: Cigna Commercial |
$5,072.20
|
| Rate for Payer: First Health Commercial |
$5,805.54
|
| Rate for Payer: Humana Commercial |
$5,194.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,011.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,509.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,833.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,377.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,583.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,222.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$794.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,894.44
|
| Rate for Payer: PHCS Commercial |
$5,866.65
|
| Rate for Payer: United Healthcare All Payer |
$5,377.76
|
|
|
GAMMAGARD SD 500mg(5gm) SDV
|
Facility
|
OP
|
$6,111.09
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
25003841
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.50 |
| Max. Negotiated Rate |
$5,866.65 |
| Rate for Payer: Aetna Commercial |
$4,705.54
|
| Rate for Payer: Anthem Medicaid |
$2,101.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,766.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$109.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.98
|
| Rate for Payer: Cash Price |
$3,055.54
|
| Rate for Payer: Cash Price |
$3,055.54
|
| Rate for Payer: Cigna Commercial |
$5,072.20
|
| Rate for Payer: First Health Commercial |
$5,805.54
|
| Rate for Payer: Humana Commercial |
$5,194.43
|
| Rate for Payer: Humana KY Medicaid |
$2,101.60
|
| Rate for Payer: Humana Medicare Advantage |
$78.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,122.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,011.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,509.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,143.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,377.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,583.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,222.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$794.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,894.44
|
| Rate for Payer: PHCS Commercial |
$5,866.65
|
| Rate for Payer: United Healthcare All Payer |
$5,377.76
|
|
|
GAMUNEX C 500mg (10gm) SDV
|
Facility
|
IP
|
$7,725.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003833
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,004.30 |
| Max. Negotiated Rate |
$7,416.36 |
| Rate for Payer: Aetna Commercial |
$5,948.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,025.80
|
| Rate for Payer: Cash Price |
$3,862.69
|
| Rate for Payer: Cigna Commercial |
$6,412.07
|
| Rate for Payer: First Health Commercial |
$7,339.11
|
| Rate for Payer: Humana Commercial |
$6,566.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,334.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,701.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,317.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,798.33
|
| Rate for Payer: Ohio Health Group HMO |
$5,794.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,394.87
|
| Rate for Payer: PHCS Commercial |
$7,416.36
|
| Rate for Payer: United Healthcare All Payer |
$6,798.33
|
|
|
GAMUNEX C 500mg (10gm) SDV
|
Facility
|
OP
|
$7,725.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003833
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.79 |
| Max. Negotiated Rate |
$7,416.36 |
| Rate for Payer: Aetna Commercial |
$5,948.54
|
| Rate for Payer: Anthem Medicaid |
$2,656.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,025.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$3,862.69
|
| Rate for Payer: Cash Price |
$3,862.69
|
| Rate for Payer: Cigna Commercial |
$6,412.07
|
| Rate for Payer: First Health Commercial |
$7,339.11
|
| Rate for Payer: Humana Commercial |
$6,566.57
|
| Rate for Payer: Humana KY Medicaid |
$2,656.76
|
| Rate for Payer: Humana Medicare Advantage |
$49.79
|
| Rate for Payer: Kentucky WC Medicaid |
$2,683.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,334.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,701.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,710.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,798.33
|
| Rate for Payer: Ohio Health Group HMO |
$5,794.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,394.87
|
| Rate for Payer: PHCS Commercial |
$7,416.36
|
| Rate for Payer: United Healthcare All Payer |
$6,798.33
|
|
