|
GAMUNEX C 500mg (1gm) SDV
|
Facility
|
IP
|
$772.54
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.43 |
| Max. Negotiated Rate |
$741.64 |
| Rate for Payer: Aetna Commercial |
$594.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$602.58
|
| Rate for Payer: Cash Price |
$386.27
|
| Rate for Payer: Cigna Commercial |
$641.21
|
| Rate for Payer: First Health Commercial |
$733.91
|
| Rate for Payer: Humana Commercial |
$656.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$633.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$570.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$231.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$679.84
|
| Rate for Payer: Ohio Health Group HMO |
$579.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$239.49
|
| Rate for Payer: PHCS Commercial |
$741.64
|
| Rate for Payer: United Healthcare All Payer |
$679.84
|
|
|
GAMUNEX C 500mg (1gm) SDV
|
Facility
|
OP
|
$772.54
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.79 |
| Max. Negotiated Rate |
$741.64 |
| Rate for Payer: Aetna Commercial |
$594.86
|
| Rate for Payer: Anthem Medicaid |
$265.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$602.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$386.27
|
| Rate for Payer: Cash Price |
$386.27
|
| Rate for Payer: Cigna Commercial |
$641.21
|
| Rate for Payer: First Health Commercial |
$733.91
|
| Rate for Payer: Humana Commercial |
$656.66
|
| Rate for Payer: Humana KY Medicaid |
$265.68
|
| Rate for Payer: Humana Medicare Advantage |
$49.79
|
| Rate for Payer: Kentucky WC Medicaid |
$268.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$633.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$570.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$271.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$679.84
|
| Rate for Payer: Ohio Health Group HMO |
$579.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$239.49
|
| Rate for Payer: PHCS Commercial |
$741.64
|
| Rate for Payer: United Healthcare All Payer |
$679.84
|
|
|
GAMUNEX C 500mg (20gm) SDV
|
Facility
|
OP
|
$15,450.75
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.79 |
| Max. Negotiated Rate |
$14,832.72 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,051.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$7,725.38
|
| Rate for Payer: Cash Price |
$7,725.38
|
| Rate for Payer: Cigna Commercial |
$12,824.12
|
| Rate for Payer: First Health Commercial |
$14,678.21
|
| Rate for Payer: Humana Commercial |
$13,133.14
|
| Rate for Payer: Humana KY Medicaid |
$5,313.51
|
| Rate for Payer: Humana Medicare Advantage |
$49.79
|
| Rate for Payer: Kentucky WC Medicaid |
$5,367.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,669.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,402.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,420.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,596.66
|
| Rate for Payer: Ohio Health Group HMO |
$11,588.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,090.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,008.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,789.73
|
| Rate for Payer: PHCS Commercial |
$14,832.72
|
| Rate for Payer: United Healthcare All Payer |
$13,596.66
|
| Rate for Payer: Aetna Commercial |
$11,897.08
|
| Rate for Payer: Anthem Medicaid |
$5,313.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.79
|
|
|
GAMUNEX C 500mg (20gm) SDV
|
Facility
|
IP
|
$15,450.75
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,008.60 |
| Max. Negotiated Rate |
$14,832.72 |
| Rate for Payer: Aetna Commercial |
$11,897.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,051.58
|
| Rate for Payer: Cash Price |
$7,725.38
|
| Rate for Payer: Cigna Commercial |
$12,824.12
|
| Rate for Payer: First Health Commercial |
$14,678.21
|
| Rate for Payer: Humana Commercial |
$13,133.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,669.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,402.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,635.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,596.66
|
| Rate for Payer: Ohio Health Group HMO |
$11,588.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,090.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,008.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,789.73
|
| Rate for Payer: PHCS Commercial |
$14,832.72
|
| Rate for Payer: United Healthcare All Payer |
$13,596.66
|
|
|
GAMUNEX C 500mg (2.5gm) SDV
|
Facility
|
OP
|
$1,931.37
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.79 |
| Max. Negotiated Rate |
$1,854.12 |
| Rate for Payer: Aetna Commercial |
$1,487.15
|
| Rate for Payer: Anthem Medicaid |
$664.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$965.68
|
| Rate for Payer: Cash Price |
$965.68
|
| Rate for Payer: Cigna Commercial |
$1,603.04
|
| Rate for Payer: First Health Commercial |
$1,834.80
|
| Rate for Payer: Humana Commercial |
$1,641.66
|
| Rate for Payer: Humana KY Medicaid |
$664.20
|
| Rate for Payer: Humana Medicare Advantage |
$49.79
|
| Rate for Payer: Kentucky WC Medicaid |
$670.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,583.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,425.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$677.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,699.61
|
| Rate for Payer: Ohio Health Group HMO |
$1,448.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$598.72
|
| Rate for Payer: PHCS Commercial |
$1,854.12
|
| Rate for Payer: United Healthcare All Payer |
$1,699.61
|
|
|
GAMUNEX C 500mg (2.5gm) SDV
|
Facility
|
IP
|
$1,931.37
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25003835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$251.08 |
| Max. Negotiated Rate |
$1,854.12 |
| Rate for Payer: Aetna Commercial |
$1,487.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.47
|
| Rate for Payer: Cash Price |
$965.68
|
| Rate for Payer: Cigna Commercial |
$1,603.04
|
| Rate for Payer: First Health Commercial |
$1,834.80
|
| Rate for Payer: Humana Commercial |
$1,641.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,583.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,425.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,699.61
|
| Rate for Payer: Ohio Health Group HMO |
$1,448.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$386.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$251.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$598.72
|
| Rate for Payer: PHCS Commercial |
$1,854.12
|
| Rate for Payer: United Healthcare All Payer |
$1,699.61
|
|
|
GAMUNEX C 500mg (40gm) SDV
|
Facility
|
OP
|
$30,901.50
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.79 |
| Max. Negotiated Rate |
$29,665.44 |
| Rate for Payer: Aetna Commercial |
$23,794.16
|
| Rate for Payer: Anthem Medicaid |
$10,627.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,103.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$15,450.75
|
| Rate for Payer: Cash Price |
$15,450.75
|
| Rate for Payer: Cigna Commercial |
$25,648.24
|
| Rate for Payer: First Health Commercial |
$29,356.42
|
| Rate for Payer: Humana Commercial |
$26,266.28
|
| Rate for Payer: Humana KY Medicaid |
$10,627.03
|
| Rate for Payer: Humana Medicare Advantage |
$49.79
|
| Rate for Payer: Kentucky WC Medicaid |
$10,735.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,339.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,805.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,840.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,193.32
|
| Rate for Payer: Ohio Health Group HMO |
$23,176.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,180.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,017.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,579.46
|
| Rate for Payer: PHCS Commercial |
$29,665.44
|
| Rate for Payer: United Healthcare All Payer |
$27,193.32
|
|
|
GAMUNEX C 500mg (40gm) SDV
|
Facility
|
IP
|
$30,901.50
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,017.20 |
| Max. Negotiated Rate |
$29,665.44 |
| Rate for Payer: Aetna Commercial |
$23,794.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,103.17
|
| Rate for Payer: Cash Price |
$15,450.75
|
| Rate for Payer: Cigna Commercial |
$25,648.24
|
| Rate for Payer: First Health Commercial |
$29,356.42
|
| Rate for Payer: Humana Commercial |
$26,266.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,339.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,805.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,270.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,193.32
|
| Rate for Payer: Ohio Health Group HMO |
$23,176.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,180.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,017.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,579.46
|
| Rate for Payer: PHCS Commercial |
$29,665.44
|
| Rate for Payer: United Healthcare All Payer |
$27,193.32
|
|
|
GAMUNEX C 500mg (5gm) SDV
|
Facility
|
IP
|
$3,862.69
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$502.15 |
| Max. Negotiated Rate |
$3,708.18 |
| Rate for Payer: Aetna Commercial |
$2,974.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,012.90
|
| Rate for Payer: Cash Price |
$1,931.35
|
| Rate for Payer: Cigna Commercial |
$3,206.03
|
| Rate for Payer: First Health Commercial |
$3,669.56
|
| Rate for Payer: Humana Commercial |
$3,283.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,167.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,850.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,158.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,399.17
|
| Rate for Payer: Ohio Health Group HMO |
$2,897.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,197.43
|
| Rate for Payer: PHCS Commercial |
$3,708.18
|
| Rate for Payer: United Healthcare All Payer |
$3,399.17
|
|
|
GAMUNEX C 500mg (5gm) SDV
|
Facility
|
OP
|
$3,862.69
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
25002087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.79 |
| Max. Negotiated Rate |
$3,708.18 |
| Rate for Payer: Aetna Commercial |
$2,974.27
|
| Rate for Payer: Anthem Medicaid |
$1,328.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,012.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$1,931.35
|
| Rate for Payer: Cash Price |
$1,931.35
|
| Rate for Payer: Cigna Commercial |
$3,206.03
|
| Rate for Payer: First Health Commercial |
$3,669.56
|
| Rate for Payer: Humana Commercial |
$3,283.29
|
| Rate for Payer: Humana KY Medicaid |
$1,328.38
|
| Rate for Payer: Humana Medicare Advantage |
$49.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,341.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,167.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,850.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,355.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,399.17
|
| Rate for Payer: Ohio Health Group HMO |
$2,897.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,197.43
|
| Rate for Payer: PHCS Commercial |
$3,708.18
|
| Rate for Payer: United Healthcare All Payer |
$3,399.17
|
|
|
GARAMYCIN(GENTAMICIN)0.1% 15GM
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 713068215
|
| Hospital Charge Code |
25000711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| 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 |
$10.80
|
| 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 |
$9.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.94
|
| 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 |
$1.65 |
| 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 |
$10.80
|
| 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 |
$9.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.94
|
| 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 |
$0.10 |
| 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 |
$0.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.25
|
| 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 |
$0.10 |
| 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 |
$0.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.25
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
GARDNERELLA VAGINALIS PCR
|
Professional
|
Both
|
$142.00
|
|
|
Service Code
|
HCPCS 87511
|
| Hospital Charge Code |
30001374
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: Aetna Commercial |
$45.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$142.00
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cigna Commercial |
$30.93
|
| Rate for Payer: Healthspan PPO |
$36.78
|
| Rate for Payer: Multiplan PHCS |
$85.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$99.40
|
| Rate for Payer: UHCCP Medicaid |
$49.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.05
|
|
|
GARDNERELLA VAGINALIS PCR
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS 87511
|
| Hospital Charge Code |
30001374
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$18.46 |
| Max. Negotiated Rate |
$136.32 |
| Rate for Payer: Aetna Commercial |
$109.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.03
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cigna Commercial |
$117.86
|
| Rate for Payer: First Health Commercial |
$134.90
|
| Rate for Payer: Humana Commercial |
$120.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.96
|
| Rate for Payer: Ohio Health Group HMO |
$106.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.02
|
| Rate for Payer: PHCS Commercial |
$136.32
|
| Rate for Payer: United Healthcare All Payer |
$124.96
|
|
|
GARDNERELLA VAGINALIS PCR
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS 87511
|
| Hospital Charge Code |
30001374
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$18.46 |
| Max. Negotiated Rate |
$136.32 |
| Rate for Payer: Aetna Commercial |
$109.34
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.03
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cigna Commercial |
$117.86
|
| Rate for Payer: First Health Commercial |
$134.90
|
| Rate for Payer: Humana Commercial |
$120.70
|
| 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 |
$116.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.96
|
| Rate for Payer: Ohio Health Group HMO |
$106.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.02
|
| Rate for Payer: PHCS Commercial |
$136.32
|
| Rate for Payer: United Healthcare All Payer |
$124.96
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Professional
|
Both
|
$262.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
46000013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$15.10 |
| Max. Negotiated Rate |
$262.00 |
| Rate for Payer: Anthem Medicaid |
$32.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$262.00
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cash Price |
$131.00
|
| 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: Molina Healthcare CHIP/Medicaid |
$33.40
|
| Rate for Payer: Molina Healthcare Passport |
$32.75
|
| Rate for Payer: Multiplan PHCS |
$157.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$183.40
|
| Rate for Payer: UHCCP Medicaid |
$91.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.08
|
|
|
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: Anthem Medicaid |
$32.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$44.00
|
| 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: Molina Healthcare CHIP/Medicaid |
$33.40
|
| Rate for Payer: Molina Healthcare Passport |
$32.75
|
| Rate for Payer: Multiplan PHCS |
$26.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.80
|
| Rate for Payer: UHCCP Medicaid |
$15.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.08
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
46000013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$34.06 |
| Max. Negotiated Rate |
$251.52 |
| Rate for Payer: Aetna Commercial |
$201.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$204.36
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cigna Commercial |
$217.46
|
| Rate for Payer: First Health Commercial |
$248.90
|
| Rate for Payer: Humana Commercial |
$222.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$193.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$230.56
|
| Rate for Payer: Ohio Health Group HMO |
$196.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.22
|
| Rate for Payer: PHCS Commercial |
$251.52
|
| Rate for Payer: United Healthcare All Payer |
$230.56
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
460T0013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem Medicaid |
$74.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Humana KY Medicaid |
$74.97
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$75.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
46000013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$34.06 |
| Max. Negotiated Rate |
$251.52 |
| Rate for Payer: Aetna Commercial |
$201.74
|
| Rate for Payer: Anthem Medicaid |
$90.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$204.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cigna Commercial |
$217.46
|
| Rate for Payer: First Health Commercial |
$248.90
|
| Rate for Payer: Humana Commercial |
$222.70
|
| Rate for Payer: Humana KY Medicaid |
$90.10
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$91.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$193.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$91.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$230.56
|
| Rate for Payer: Ohio Health Group HMO |
$196.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.22
|
| Rate for Payer: PHCS Commercial |
$251.52
|
| Rate for Payer: United Healthcare All Payer |
$230.56
|
|
|
GAS DILUTE/WASH DETERM LUNGVOL
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
460T0013
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.58
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
GASTRE PARTIAL - DISL; GASTRO
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 43632
|
| Hospital Charge Code |
76101785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$928.88 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,832.92
|
| Rate for Payer: Anthem Medicaid |
$928.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,563.49
|
| Rate for Payer: Healthspan PPO |
$2,389.05
|
| Rate for Payer: Humana Medicaid |
$928.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,584.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$947.46
|
| Rate for Payer: Molina Healthcare Passport |
$928.88
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$938.17
|
|
|
GASTRE PARTIAL - DISL; GASTRO
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 43632
|
| Hospital Charge Code |
76101785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
