|
OCCULT BLOOD 1-3
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 82272
|
| Hospital Charge Code |
30000253
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$4.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.23
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$4.23
|
| Rate for Payer: Humana Medicare Advantage |
$4.23
|
| Rate for Payer: Kentucky WC Medicaid |
$4.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
OCCULT BLOOD 1-3
|
Professional
|
Both
|
$68.00
|
|
|
Service Code
|
HCPCS 82272
|
| Hospital Charge Code |
30000253
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$68.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$4.61
|
| Rate for Payer: Healthspan PPO |
$3.41
|
| Rate for Payer: Multiplan PHCS |
$40.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$47.60
|
| Rate for Payer: UHCCP Medicaid |
$23.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2.54
|
|
|
OCELOT 6F 110CM
|
Facility
|
OP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem Medicaid |
$4,266.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Humana KY Medicaid |
$4,266.68
|
| Rate for Payer: Kentucky WC Medicaid |
$4,310.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,352.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
OCELOT 6F 110CM
|
Facility
|
IP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
OCELOT/MVRX 6F 110CM
|
Facility
|
OP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem Medicaid |
$4,266.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Humana KY Medicaid |
$4,266.68
|
| Rate for Payer: Kentucky WC Medicaid |
$4,310.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,352.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
OCELOT/MVRX 6F 110CM
|
Facility
|
IP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
OCELOT/PIXL 5F 135CM
|
Facility
|
IP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
OCELOT/PIXL 5F 135CM
|
Facility
|
OP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem Medicaid |
$4,266.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Humana KY Medicaid |
$4,266.68
|
| Rate for Payer: Kentucky WC Medicaid |
$4,310.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,352.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
OCREVUS 1mg (300mg Vial)
|
Facility
|
OP
|
$107,443.37
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
25002260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.75 |
| Max. Negotiated Rate |
$103,145.64 |
| Rate for Payer: Ohio Health Group HMO |
$80,582.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,488.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33,307.44
|
| Rate for Payer: PHCS Commercial |
$103,145.64
|
| Rate for Payer: United Healthcare All Payer |
$94,550.17
|
| Rate for Payer: Aetna Commercial |
$82,731.39
|
| Rate for Payer: Anthem Medicaid |
$36,949.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$59.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83,805.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$83.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$80.66
|
| Rate for Payer: Cash Price |
$53,721.68
|
| Rate for Payer: Cash Price |
$53,721.68
|
| Rate for Payer: Cigna Commercial |
$89,178.00
|
| Rate for Payer: First Health Commercial |
$102,071.20
|
| Rate for Payer: Humana Commercial |
$91,326.86
|
| Rate for Payer: Humana KY Medicaid |
$36,949.77
|
| Rate for Payer: Humana Medicare Advantage |
$59.75
|
| Rate for Payer: Kentucky WC Medicaid |
$37,325.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88,103.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79,293.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$71.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$37,691.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$94,550.17
|
|
|
OCREVUS 1mg (300mg Vial)
|
Facility
|
IP
|
$107,443.37
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
25002260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,967.64 |
| Max. Negotiated Rate |
$103,145.64 |
| Rate for Payer: Aetna Commercial |
$82,731.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83,805.83
|
| Rate for Payer: Cash Price |
$53,721.68
|
| Rate for Payer: Cigna Commercial |
$89,178.00
|
| Rate for Payer: First Health Commercial |
$102,071.20
|
| Rate for Payer: Humana Commercial |
$91,326.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88,103.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79,293.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32,233.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$94,550.17
|
| Rate for Payer: Ohio Health Group HMO |
$80,582.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,488.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33,307.44
|
| Rate for Payer: PHCS Commercial |
$103,145.64
|
| Rate for Payer: United Healthcare All Payer |
$94,550.17
|
|
|
OCTAGAM 10% 500mg (10gm) SDV
|
Facility
|
IP
|
$10,586.63
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,376.26 |
| Max. Negotiated Rate |
$10,163.16 |
| Rate for Payer: Aetna Commercial |
$8,151.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,257.57
|
| Rate for Payer: Cash Price |
$5,293.31
|
| Rate for Payer: Cigna Commercial |
$8,786.90
|
| Rate for Payer: First Health Commercial |
$10,057.30
|
| Rate for Payer: Humana Commercial |
$8,998.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,681.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,812.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,175.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,316.23
|
| Rate for Payer: Ohio Health Group HMO |
$7,939.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,117.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,376.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,281.86
|
| Rate for Payer: PHCS Commercial |
$10,163.16
|
| Rate for Payer: United Healthcare All Payer |
$9,316.23
|
|
|
OCTAGAM 10% 500mg (10gm) SDV
|
Facility
|
OP
|
$10,586.63
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$10,163.16 |
| Rate for Payer: Aetna Commercial |
$8,151.71
|
| Rate for Payer: Anthem Medicaid |
$3,640.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,257.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$5,293.31
|
| Rate for Payer: Cash Price |
$5,293.31
|
| Rate for Payer: Cigna Commercial |
$8,786.90
|
| Rate for Payer: First Health Commercial |
$10,057.30
|
| Rate for Payer: Humana Commercial |
$8,998.64
|
| Rate for Payer: Humana KY Medicaid |
$3,640.74
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$3,677.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,681.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,812.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,713.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,316.23
|
| Rate for Payer: Ohio Health Group HMO |
$7,939.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,117.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,376.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,281.86
|
| Rate for Payer: PHCS Commercial |
$10,163.16
|
| Rate for Payer: United Healthcare All Payer |
$9,316.23
|
|
|
OCTAGAM 10% 500mg (20gm) SDV
|
Facility
|
IP
|
$21,173.25
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,752.52 |
| Max. Negotiated Rate |
$20,326.32 |
| Rate for Payer: Aetna Commercial |
$16,303.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,515.14
|
| Rate for Payer: Cash Price |
$10,586.62
|
| Rate for Payer: Cigna Commercial |
$17,573.80
|
| Rate for Payer: First Health Commercial |
$20,114.59
|
| Rate for Payer: Humana Commercial |
$17,997.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,362.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,625.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,351.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,632.46
|
| Rate for Payer: Ohio Health Group HMO |
$15,879.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,234.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,752.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,563.71
|
| Rate for Payer: PHCS Commercial |
$20,326.32
|
| Rate for Payer: United Healthcare All Payer |
$18,632.46
|
|
|
OCTAGAM 10% 500mg (20gm) SDV
|
Facility
|
OP
|
$21,173.25
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$20,326.32 |
| Rate for Payer: Aetna Commercial |
$16,303.40
|
| Rate for Payer: Anthem Medicaid |
$7,281.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,515.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$10,586.62
|
| Rate for Payer: Cash Price |
$10,586.62
|
| Rate for Payer: Cigna Commercial |
$17,573.80
|
| Rate for Payer: First Health Commercial |
$20,114.59
|
| Rate for Payer: Humana Commercial |
$17,997.26
|
| Rate for Payer: Humana KY Medicaid |
$7,281.48
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,355.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,362.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,625.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,427.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,632.46
|
| Rate for Payer: Ohio Health Group HMO |
$15,879.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,234.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,752.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,563.71
|
| Rate for Payer: PHCS Commercial |
$20,326.32
|
| Rate for Payer: United Healthcare All Payer |
$18,632.46
|
|
|
OCTAGAM 10% 500mg (30gm) SDV
|
Facility
|
IP
|
$31,759.88
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,128.78 |
| Max. Negotiated Rate |
$30,489.48 |
| Rate for Payer: Aetna Commercial |
$24,455.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,772.71
|
| Rate for Payer: Cash Price |
$15,879.94
|
| Rate for Payer: Cigna Commercial |
$26,360.70
|
| Rate for Payer: First Health Commercial |
$30,171.89
|
| Rate for Payer: Humana Commercial |
$26,995.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,043.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,438.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,527.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,948.69
|
| Rate for Payer: Ohio Health Group HMO |
$23,819.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,351.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,128.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,845.56
|
| Rate for Payer: PHCS Commercial |
$30,489.48
|
| Rate for Payer: United Healthcare All Payer |
$27,948.69
|
|
|
OCTAGAM 10% 500mg (30gm) SDV
|
Facility
|
OP
|
$31,759.88
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$30,489.48 |
| Rate for Payer: Aetna Commercial |
$24,455.11
|
| Rate for Payer: Anthem Medicaid |
$10,922.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,772.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$15,879.94
|
| Rate for Payer: Cash Price |
$15,879.94
|
| Rate for Payer: Cigna Commercial |
$26,360.70
|
| Rate for Payer: First Health Commercial |
$30,171.89
|
| Rate for Payer: Humana Commercial |
$26,995.90
|
| Rate for Payer: Humana KY Medicaid |
$10,922.22
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$11,033.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,043.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,438.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,141.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,948.69
|
| Rate for Payer: Ohio Health Group HMO |
$23,819.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,351.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,128.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,845.56
|
| Rate for Payer: PHCS Commercial |
$30,489.48
|
| Rate for Payer: United Healthcare All Payer |
$27,948.69
|
|
|
OCTAGAM 10% 500mg (5gm) SDV
|
Facility
|
OP
|
$5,293.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$5,081.58 |
| Rate for Payer: Aetna Commercial |
$4,075.85
|
| Rate for Payer: Anthem Medicaid |
$1,820.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,128.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$2,646.66
|
| Rate for Payer: Cash Price |
$2,646.66
|
| Rate for Payer: Cigna Commercial |
$4,393.45
|
| Rate for Payer: First Health Commercial |
$5,028.64
|
| Rate for Payer: Humana Commercial |
$4,499.31
|
| Rate for Payer: Humana KY Medicaid |
$1,820.37
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,838.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,340.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,906.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,856.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,658.11
|
| Rate for Payer: Ohio Health Group HMO |
$3,969.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,058.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$688.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,640.93
|
| Rate for Payer: PHCS Commercial |
$5,081.58
|
| Rate for Payer: United Healthcare All Payer |
$4,658.11
|
|
|
OCTAGAM 10% 500mg (5gm) SDV
|
Facility
|
IP
|
$5,293.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25004301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$688.13 |
| Max. Negotiated Rate |
$5,081.58 |
| Rate for Payer: Aetna Commercial |
$4,075.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,128.78
|
| Rate for Payer: Cash Price |
$2,646.66
|
| Rate for Payer: Cigna Commercial |
$4,393.45
|
| Rate for Payer: First Health Commercial |
$5,028.64
|
| Rate for Payer: Humana Commercial |
$4,499.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,340.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,906.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,587.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,658.11
|
| Rate for Payer: Ohio Health Group HMO |
$3,969.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,058.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$688.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,640.93
|
| Rate for Payer: PHCS Commercial |
$5,081.58
|
| Rate for Payer: United Healthcare All Payer |
$4,658.11
|
|
|
OCTAGAM 5% 500mg (10gm) SDV
|
Facility
|
IP
|
$10,586.63
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25002095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,376.26 |
| Max. Negotiated Rate |
$10,163.16 |
| Rate for Payer: Aetna Commercial |
$8,151.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,257.57
|
| Rate for Payer: Cash Price |
$5,293.31
|
| Rate for Payer: Cigna Commercial |
$8,786.90
|
| Rate for Payer: First Health Commercial |
$10,057.30
|
| Rate for Payer: Humana Commercial |
$8,998.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,681.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,812.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,175.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,316.23
|
| Rate for Payer: Ohio Health Group HMO |
$7,939.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,117.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,376.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,281.86
|
| Rate for Payer: PHCS Commercial |
$10,163.16
|
| Rate for Payer: United Healthcare All Payer |
$9,316.23
|
|
|
OCTAGAM 5% 500mg (10gm) SDV
|
Facility
|
OP
|
$10,586.63
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25002095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$10,163.16 |
| Rate for Payer: Aetna Commercial |
$8,151.71
|
| Rate for Payer: Anthem Medicaid |
$3,640.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,257.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$5,293.31
|
| Rate for Payer: Cash Price |
$5,293.31
|
| Rate for Payer: Cigna Commercial |
$8,786.90
|
| Rate for Payer: First Health Commercial |
$10,057.30
|
| Rate for Payer: Humana Commercial |
$8,998.64
|
| Rate for Payer: Humana KY Medicaid |
$3,640.74
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$3,677.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,681.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,812.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,713.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,316.23
|
| Rate for Payer: Ohio Health Group HMO |
$7,939.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,117.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,376.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,281.86
|
| Rate for Payer: PHCS Commercial |
$10,163.16
|
| Rate for Payer: United Healthcare All Payer |
$9,316.23
|
|
|
OCTAGAM 5% 500mg (1gm) SDV
|
Facility
|
IP
|
$1,058.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.63 |
| Max. Negotiated Rate |
$1,016.31 |
| Rate for Payer: Aetna Commercial |
$815.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$825.75
|
| Rate for Payer: Cash Price |
$529.33
|
| Rate for Payer: Cigna Commercial |
$878.69
|
| Rate for Payer: First Health Commercial |
$1,005.73
|
| Rate for Payer: Humana Commercial |
$899.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$868.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$781.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$931.62
|
| Rate for Payer: Ohio Health Group HMO |
$794.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$328.18
|
| Rate for Payer: PHCS Commercial |
$1,016.31
|
| Rate for Payer: United Healthcare All Payer |
$931.62
|
|
|
OCTAGAM 5% 500mg (1gm) SDV
|
Facility
|
OP
|
$1,058.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$1,016.31 |
| Rate for Payer: Aetna Commercial |
$815.17
|
| Rate for Payer: Anthem Medicaid |
$364.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$825.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$529.33
|
| Rate for Payer: Cash Price |
$529.33
|
| Rate for Payer: Cigna Commercial |
$878.69
|
| Rate for Payer: First Health Commercial |
$1,005.73
|
| Rate for Payer: Humana Commercial |
$899.86
|
| Rate for Payer: Humana KY Medicaid |
$364.07
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$367.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$868.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$781.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$371.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$931.62
|
| Rate for Payer: Ohio Health Group HMO |
$794.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$328.18
|
| Rate for Payer: PHCS Commercial |
$1,016.31
|
| Rate for Payer: United Healthcare All Payer |
$931.62
|
|
|
OCTAGAM 5% 500mg (25gm) SDV
|
Facility
|
OP
|
$20,201.79
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$19,393.72 |
| Rate for Payer: Ohio Health Group HMO |
$15,151.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,040.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,626.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,262.55
|
| Rate for Payer: PHCS Commercial |
$19,393.72
|
| Rate for Payer: United Healthcare All Payer |
$17,777.58
|
| Rate for Payer: Aetna Commercial |
$15,555.38
|
| Rate for Payer: Anthem Medicaid |
$6,947.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,757.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.72
|
| Rate for Payer: Cash Price |
$10,100.90
|
| Rate for Payer: Cash Price |
$10,100.90
|
| Rate for Payer: Cigna Commercial |
$16,767.49
|
| Rate for Payer: First Health Commercial |
$19,191.70
|
| Rate for Payer: Humana Commercial |
$17,171.52
|
| Rate for Payer: Humana KY Medicaid |
$6,947.40
|
| Rate for Payer: Humana Medicare Advantage |
$44.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,018.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,565.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,908.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,086.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,777.58
|
|
|
OCTAGAM 5% 500mg (25gm) SDV
|
Facility
|
IP
|
$20,201.79
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,626.23 |
| Max. Negotiated Rate |
$19,393.72 |
| Rate for Payer: Aetna Commercial |
$15,555.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,757.40
|
| Rate for Payer: Cash Price |
$10,100.90
|
| Rate for Payer: Cigna Commercial |
$16,767.49
|
| Rate for Payer: First Health Commercial |
$19,191.70
|
| Rate for Payer: Humana Commercial |
$17,171.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,565.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,908.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,060.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,777.58
|
| Rate for Payer: Ohio Health Group HMO |
$15,151.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,040.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,626.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,262.55
|
| Rate for Payer: PHCS Commercial |
$19,393.72
|
| Rate for Payer: United Healthcare All Payer |
$17,777.58
|
|
|
OCTAGAM 5% 500mg (2.5gm) SDV
|
Facility
|
IP
|
$2,646.68
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.07 |
| Max. Negotiated Rate |
$2,540.81 |
| Rate for Payer: Aetna Commercial |
$2,037.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,064.41
|
| Rate for Payer: Cash Price |
$1,323.34
|
| Rate for Payer: Cigna Commercial |
$2,196.74
|
| Rate for Payer: First Health Commercial |
$2,514.35
|
| Rate for Payer: Humana Commercial |
$2,249.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,170.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,953.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$794.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,329.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,985.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$529.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$344.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$820.47
|
| Rate for Payer: PHCS Commercial |
$2,540.81
|
| Rate for Payer: United Healthcare All Payer |
$2,329.08
|
|
