|
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 |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,257.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$8,469.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,210.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,304.77
|
| Rate for Payer: PHCS Commercial |
$10,163.16
|
| Rate for Payer: United Healthcare All Payer |
$9,316.23
|
|
|
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 |
$3,175.99 |
| 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 |
$8,469.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,210.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,304.77
|
| Rate for Payer: PHCS Commercial |
$10,163.16
|
| Rate for Payer: United Healthcare All Payer |
$9,316.23
|
|
|
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 |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,515.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$16,938.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,420.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,609.54
|
| Rate for Payer: PHCS Commercial |
$20,326.32
|
| Rate for Payer: United Healthcare All Payer |
$18,632.46
|
|
|
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 |
$6,351.98 |
| Max. Negotiated Rate |
$20,326.32 |
| Rate for Payer: Aetna Commercial |
$16,303.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,515.13
|
| 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 |
$16,938.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,420.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,609.54
|
| 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 |
$9,527.96 |
| 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 |
$25,407.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27,631.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,914.32
|
| 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 |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,772.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$25,407.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27,631.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,914.32
|
| Rate for Payer: PHCS Commercial |
$30,489.48
|
| Rate for Payer: United Healthcare All Payer |
$27,948.69
|
|
|
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 |
$1,587.99 |
| 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 |
$4,234.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,605.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,652.38
|
| Rate for Payer: PHCS Commercial |
$5,081.58
|
| Rate for Payer: United Healthcare All Payer |
$4,658.11
|
|
|
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 |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,128.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$4,234.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,605.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,652.38
|
| 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 |
$3,175.99 |
| 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 |
$8,469.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,210.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,304.77
|
| 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 |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,257.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$8,469.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,210.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,304.77
|
| 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 |
$317.60 |
| 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 |
$846.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$921.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$730.48
|
| 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 |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$825.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$846.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$921.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$730.48
|
| 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 |
$48.38 |
| Max. Negotiated Rate |
$19,393.72 |
| Rate for Payer: Aetna Commercial |
$15,555.38
|
| Rate for Payer: Anthem Medicaid |
$6,947.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,757.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,086.79
|
| 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 |
$16,161.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,575.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,939.24
|
| Rate for Payer: PHCS Commercial |
$19,393.72
|
| Rate for Payer: United Healthcare All Payer |
$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 |
$6,060.54 |
| 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 |
$16,161.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,575.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,939.24
|
| 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
|
OP
|
$2,646.68
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.38 |
| Max. Negotiated Rate |
$2,540.81 |
| Rate for Payer: Aetna Commercial |
$2,037.94
|
| Rate for Payer: Anthem Medicaid |
$910.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,064.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| Rate for Payer: Cash Price |
$1,323.34
|
| 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: Humana KY Medicaid |
$910.19
|
| Rate for Payer: Humana Medicare Advantage |
$48.38
|
| Rate for Payer: Kentucky WC Medicaid |
$919.46
|
| 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 |
$58.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$928.46
|
| 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 |
$2,117.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,302.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,826.21
|
| Rate for Payer: PHCS Commercial |
$2,540.81
|
| Rate for Payer: United Healthcare All Payer |
$2,329.08
|
|
|
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 |
$794.00 |
| 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 |
$2,117.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,302.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,826.21
|
| Rate for Payer: PHCS Commercial |
$2,540.81
|
| Rate for Payer: United Healthcare All Payer |
$2,329.08
|
|
|
OCTAGAM 5% 500mg (5gm) SDV
|
Facility
|
IP
|
$5,293.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,587.99 |
| 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 |
$4,234.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,605.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,652.38
|
| Rate for Payer: PHCS Commercial |
$5,081.58
|
| Rate for Payer: United Healthcare All Payer |
$4,658.11
|
|
|
OCTAGAM 5% 500mg (5gm) SDV
|
Facility
|
OP
|
$5,293.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
25003832
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.38 |
| 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 |
$48.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,128.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.31
|
| 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 |
$48.38
|
| 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 |
$58.06
|
| 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 |
$4,234.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,605.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,652.38
|
| Rate for Payer: PHCS Commercial |
$5,081.58
|
| Rate for Payer: United Healthcare All Payer |
$4,658.11
|
|
|
OCTREOTIDE 50mcg/mL AMPUL IV a
|
Facility
|
IP
|
$121.12
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25004019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.34 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.47
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.53
|
| Rate for Payer: First Health Commercial |
$115.06
|
| Rate for Payer: Humana Commercial |
$102.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.57
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
OCTREOTIDE 50mcg/mL AMPUL IV a
|
Facility
|
OP
|
$121.12
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25004019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.34 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.26
|
| Rate for Payer: Anthem Medicaid |
$41.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.47
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.53
|
| Rate for Payer: First Health Commercial |
$115.06
|
| Rate for Payer: Humana Commercial |
$102.95
|
| Rate for Payer: Humana KY Medicaid |
$41.65
|
| Rate for Payer: Kentucky WC Medicaid |
$42.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.57
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
OCTREOTIDE 50mcg/mL AMPUL SubQ
|
Facility
|
IP
|
$121.12
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25004018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.34 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.47
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.53
|
| Rate for Payer: First Health Commercial |
$115.06
|
| Rate for Payer: Humana Commercial |
$102.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.57
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
OCTREOTIDE 50mcg/mL AMPUL SubQ
|
Facility
|
OP
|
$121.12
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25004018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.34 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna Commercial |
$93.26
|
| Rate for Payer: Anthem Medicaid |
$41.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.47
|
| Rate for Payer: Cash Price |
$60.56
|
| Rate for Payer: Cigna Commercial |
$100.53
|
| Rate for Payer: First Health Commercial |
$115.06
|
| Rate for Payer: Humana Commercial |
$102.95
|
| Rate for Payer: Humana KY Medicaid |
$41.65
|
| Rate for Payer: Kentucky WC Medicaid |
$42.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.59
|
| Rate for Payer: Ohio Health Group HMO |
$90.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.57
|
| Rate for Payer: PHCS Commercial |
$116.28
|
| Rate for Payer: United Healthcare All Payer |
$106.59
|
|
|
OCUFEN (FLURBIPROFEN).03 2.5ML
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
NDC 69292072225
|
| Hospital Charge Code |
25001118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.20 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.06
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
OCUFEN (FLURBIPROFEN).03 2.5ML
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
NDC 69292072225
|
| Hospital Charge Code |
25001118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.20 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem Medicaid |
$25.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Humana KY Medicaid |
$25.45
|
| Rate for Payer: Kentucky WC Medicaid |
$25.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.06
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
OCULAR INSTRUMNT SCREEN BIL
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS 99177
|
| Hospital Charge Code |
51000354
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Aetna Commercial |
$10.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.14
|
| Rate for Payer: Cash Price |
$6.50
|
| Rate for Payer: Cigna Commercial |
$10.79
|
| Rate for Payer: First Health Commercial |
$12.35
|
| Rate for Payer: Humana Commercial |
$11.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.44
|
| Rate for Payer: Ohio Health Group HMO |
$9.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.97
|
| Rate for Payer: PHCS Commercial |
$12.48
|
| Rate for Payer: United Healthcare All Payer |
$11.44
|
|
