|
CXI SUPPORT CATH. .018 STR 150
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
CXI SUPPORT CATH .035 ANG 150
|
Facility
|
IP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH .035 ANG 150
|
Facility
|
OP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem Medicaid |
$698.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Humana KY Medicaid |
$698.98
|
| Rate for Payer: Kentucky WC Medicaid |
$706.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$713.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .035 STR 150
|
Facility
|
OP
|
$2,042.76
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$265.56 |
| Max. Negotiated Rate |
$1,961.05 |
| Rate for Payer: Aetna Commercial |
$1,572.93
|
| Rate for Payer: Anthem Medicaid |
$702.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,593.35
|
| Rate for Payer: Cash Price |
$1,021.38
|
| Rate for Payer: Cigna Commercial |
$1,695.49
|
| Rate for Payer: First Health Commercial |
$1,940.62
|
| Rate for Payer: Humana Commercial |
$1,736.35
|
| Rate for Payer: Humana KY Medicaid |
$702.51
|
| Rate for Payer: Kentucky WC Medicaid |
$709.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,675.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,507.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$612.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$716.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,797.63
|
| Rate for Payer: Ohio Health Group HMO |
$1,532.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.26
|
| Rate for Payer: PHCS Commercial |
$1,961.05
|
| Rate for Payer: United Healthcare All Payer |
$1,797.63
|
|
|
CXI SUPPORT CATH. .035 STR 150
|
Facility
|
IP
|
$2,042.76
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$265.56 |
| Max. Negotiated Rate |
$1,961.05 |
| Rate for Payer: Aetna Commercial |
$1,572.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,593.35
|
| Rate for Payer: Cash Price |
$1,021.38
|
| Rate for Payer: Cigna Commercial |
$1,695.49
|
| Rate for Payer: First Health Commercial |
$1,940.62
|
| Rate for Payer: Humana Commercial |
$1,736.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,675.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,507.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$612.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,797.63
|
| Rate for Payer: Ohio Health Group HMO |
$1,532.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.26
|
| Rate for Payer: PHCS Commercial |
$1,961.05
|
| Rate for Payer: United Healthcare All Payer |
$1,797.63
|
|
|
CXR INCLUDING APICAL LORDOTIC
|
Facility
|
IP
|
$476.00
|
|
|
Service Code
|
HCPCS 71047
|
| Hospital Charge Code |
32000036
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$61.88 |
| Max. Negotiated Rate |
$456.96 |
| Rate for Payer: Aetna Commercial |
$366.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$371.28
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cigna Commercial |
$395.08
|
| Rate for Payer: First Health Commercial |
$452.20
|
| Rate for Payer: Humana Commercial |
$404.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$390.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$351.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.88
|
| Rate for Payer: Ohio Health Group HMO |
$357.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.56
|
| Rate for Payer: PHCS Commercial |
$456.96
|
| Rate for Payer: United Healthcare All Payer |
$418.88
|
|
|
CXR INCLUDING APICAL LORDOTIC
|
Professional
|
Both
|
$476.00
|
|
|
Service Code
|
HCPCS 71047
|
| Hospital Charge Code |
32000036
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$476.00 |
| Rate for Payer: Anthem Medicaid |
$29.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$476.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cigna Commercial |
$61.57
|
| Rate for Payer: Humana Medicaid |
$29.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$17.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$30.03
|
| Rate for Payer: Molina Healthcare Passport |
$29.44
|
| Rate for Payer: Multiplan PHCS |
$285.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$333.20
|
| Rate for Payer: UHCCP Medicaid |
$166.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.73
|
|
|
CXR INCLUDING APICAL LORDOTIC
|
Facility
|
OP
|
$476.00
|
|
|
Service Code
|
HCPCS 71047
|
| Hospital Charge Code |
32000036
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$61.88 |
| Max. Negotiated Rate |
$456.96 |
| Rate for Payer: Aetna Commercial |
$366.52
|
| Rate for Payer: Anthem Medicaid |
$163.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$371.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cigna Commercial |
$395.08
|
| Rate for Payer: First Health Commercial |
$452.20
|
| Rate for Payer: Humana Commercial |
$404.60
|
| Rate for Payer: Humana KY Medicaid |
$163.70
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$165.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$390.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$351.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$166.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.88
|
| Rate for Payer: Ohio Health Group HMO |
$357.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.56
|
| Rate for Payer: PHCS Commercial |
$456.96
|
| Rate for Payer: United Healthcare All Payer |
$418.88
|
|
|
CXR INCLUDING APICAL LORDOTI(P
|
Professional
|
Both
|
$155.00
|
|
|
Service Code
|
HCPCS 71047
|
| Hospital Charge Code |
320P0036
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Anthem Medicaid |
$29.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.00
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$61.57
|
| Rate for Payer: Humana Medicaid |
$29.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$17.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$30.03
|
| Rate for Payer: Molina Healthcare Passport |
$29.44
|
| Rate for Payer: Multiplan PHCS |
$93.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$108.50
|
| Rate for Payer: UHCCP Medicaid |
$54.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.73
|
|
|
CXR INCLUDING APICAL LORDOTI(T
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS 71047
|
| Hospital Charge Code |
320T0036
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$41.73 |
| Max. Negotiated Rate |
$308.16 |
| Rate for Payer: Aetna Commercial |
$247.17
|
| Rate for Payer: Anthem Medicaid |
$110.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$266.43
|
| Rate for Payer: First Health Commercial |
$304.95
|
| Rate for Payer: Humana Commercial |
$272.85
|
| Rate for Payer: Humana KY Medicaid |
$110.39
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$111.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.48
|
| Rate for Payer: Ohio Health Group HMO |
$240.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.51
|
| Rate for Payer: PHCS Commercial |
$308.16
|
| Rate for Payer: United Healthcare All Payer |
$282.48
|
|
|
CXR INCLUDING APICAL LORDOTI(T
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS 71047
|
| Hospital Charge Code |
320T0036
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$41.73 |
| Max. Negotiated Rate |
$308.16 |
| Rate for Payer: Aetna Commercial |
$247.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.38
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$266.43
|
| Rate for Payer: First Health Commercial |
$304.95
|
| Rate for Payer: Humana Commercial |
$272.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.48
|
| Rate for Payer: Ohio Health Group HMO |
$240.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.51
|
| Rate for Payer: PHCS Commercial |
$308.16
|
| Rate for Payer: United Healthcare All Payer |
$282.48
|
|
|
CYANIDE(SOD.THI/SONI)ANTIDSKIT
|
Facility
|
OP
|
$656.00
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
25002975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.28 |
| Max. Negotiated Rate |
$629.76 |
| Rate for Payer: Aetna Commercial |
$505.12
|
| Rate for Payer: Anthem Medicaid |
$225.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$511.68
|
| Rate for Payer: Cash Price |
$328.00
|
| Rate for Payer: Cigna Commercial |
$544.48
|
| Rate for Payer: First Health Commercial |
$623.20
|
| Rate for Payer: Humana Commercial |
$557.60
|
| Rate for Payer: Humana KY Medicaid |
$225.60
|
| Rate for Payer: Kentucky WC Medicaid |
$227.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$484.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$230.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$577.28
|
| Rate for Payer: Ohio Health Group HMO |
$492.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.36
|
| Rate for Payer: PHCS Commercial |
$629.76
|
| Rate for Payer: United Healthcare All Payer |
$577.28
|
|
|
CYANIDE(SOD.THI/SONI)ANTIDSKIT
|
Facility
|
IP
|
$656.00
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
25002975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.28 |
| Max. Negotiated Rate |
$629.76 |
| Rate for Payer: Aetna Commercial |
$505.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$511.68
|
| Rate for Payer: Cash Price |
$328.00
|
| Rate for Payer: Cigna Commercial |
$544.48
|
| Rate for Payer: First Health Commercial |
$623.20
|
| Rate for Payer: Humana Commercial |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$484.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$577.28
|
| Rate for Payer: Ohio Health Group HMO |
$492.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.36
|
| Rate for Payer: PHCS Commercial |
$629.76
|
| Rate for Payer: United Healthcare All Payer |
$577.28
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
IP
|
$108.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
636T0067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$83.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna Commercial |
$90.40
|
| Rate for Payer: First Health Commercial |
$103.46
|
| Rate for Payer: Humana Commercial |
$92.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.84
|
| Rate for Payer: Ohio Health Group HMO |
$81.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.76
|
| Rate for Payer: PHCS Commercial |
$104.55
|
| Rate for Payer: United Healthcare All Payer |
$95.84
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
IP
|
$108.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
63600067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$83.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna Commercial |
$90.40
|
| Rate for Payer: First Health Commercial |
$103.46
|
| Rate for Payer: Humana Commercial |
$92.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.84
|
| Rate for Payer: Ohio Health Group HMO |
$81.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.76
|
| Rate for Payer: PHCS Commercial |
$104.55
|
| Rate for Payer: United Healthcare All Payer |
$95.84
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Professional
|
Both
|
$108.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
63600067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$108.91 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.91
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Healthspan PPO |
$0.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2.82
|
| Rate for Payer: Multiplan PHCS |
$65.35
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$76.24
|
| Rate for Payer: UHCCP Medicaid |
$38.12
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
OP
|
$108.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
636T0067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$83.86
|
| Rate for Payer: Anthem Medicaid |
$37.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna Commercial |
$90.40
|
| Rate for Payer: First Health Commercial |
$103.46
|
| Rate for Payer: Humana Commercial |
$92.57
|
| Rate for Payer: Humana KY Medicaid |
$37.45
|
| Rate for Payer: Kentucky WC Medicaid |
$37.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.84
|
| Rate for Payer: Ohio Health Group HMO |
$81.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.76
|
| Rate for Payer: PHCS Commercial |
$104.55
|
| Rate for Payer: United Healthcare All Payer |
$95.84
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
IP
|
$113.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
25002426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$109.35 |
| Rate for Payer: Aetna Commercial |
$87.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.85
|
| Rate for Payer: Cash Price |
$56.95
|
| Rate for Payer: Cigna Commercial |
$94.55
|
| Rate for Payer: First Health Commercial |
$108.21
|
| Rate for Payer: Humana Commercial |
$96.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.24
|
| Rate for Payer: Ohio Health Group HMO |
$85.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.31
|
| Rate for Payer: PHCS Commercial |
$109.35
|
| Rate for Payer: United Healthcare All Payer |
$100.24
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
OP
|
$113.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
25002426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$109.35 |
| Rate for Payer: Aetna Commercial |
$87.71
|
| Rate for Payer: Anthem Medicaid |
$39.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.85
|
| Rate for Payer: Cash Price |
$56.95
|
| Rate for Payer: Cigna Commercial |
$94.55
|
| Rate for Payer: First Health Commercial |
$108.21
|
| Rate for Payer: Humana Commercial |
$96.82
|
| Rate for Payer: Humana KY Medicaid |
$39.17
|
| Rate for Payer: Kentucky WC Medicaid |
$39.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.24
|
| Rate for Payer: Ohio Health Group HMO |
$85.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.31
|
| Rate for Payer: PHCS Commercial |
$109.35
|
| Rate for Payer: United Healthcare All Payer |
$100.24
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
OP
|
$108.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
63600067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$104.55 |
| Rate for Payer: Aetna Commercial |
$83.86
|
| Rate for Payer: Anthem Medicaid |
$37.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$84.95
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna Commercial |
$90.40
|
| Rate for Payer: First Health Commercial |
$103.46
|
| Rate for Payer: Humana Commercial |
$92.57
|
| Rate for Payer: Humana KY Medicaid |
$37.45
|
| Rate for Payer: Kentucky WC Medicaid |
$37.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$89.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$80.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$38.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.84
|
| Rate for Payer: Ohio Health Group HMO |
$81.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.76
|
| Rate for Payer: PHCS Commercial |
$104.55
|
| Rate for Payer: United Healthcare All Payer |
$95.84
|
|
|
CYCLOGYL 0.5% 15 ML (per Drop)
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 65039515
|
| Hospital Charge Code |
25003966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
CYCLOGYL 0.5% 15 ML (per Drop)
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 65039515
|
| Hospital Charge Code |
25003966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
CYCLOGYL 1% 15 ML (per Drop)
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
CYCLOGYL 1% 15 ML (per Drop)
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
CYCLOGYL 2% 2 ML (per Drop)
|
Facility
|
IP
|
$9.10
|
|
|
Service Code
|
NDC 65039702
|
| Hospital Charge Code |
25003967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
