|
CYCLOGYL 2% 2 ML (per Drop)
|
Facility
|
OP
|
$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 Medicaid |
$3.13
|
| 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: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| 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: Molina Healthcare Medicaid |
$3.19
|
| 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
|
|
|
CYCLOGYL 2% 5 ML (per Drop)
|
Facility
|
IP
|
$4.93
|
|
|
Service Code
|
NDC 65039705
|
| Hospital Charge Code |
25003968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.09
|
| Rate for Payer: First Health Commercial |
$4.68
|
| Rate for Payer: Humana Commercial |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.34
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
CYCLOGYL 2% 5 ML (per Drop)
|
Facility
|
OP
|
$4.93
|
|
|
Service Code
|
NDC 65039705
|
| Hospital Charge Code |
25003968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.09
|
| Rate for Payer: First Health Commercial |
$4.68
|
| Rate for Payer: Humana Commercial |
$4.19
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.34
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
CYCLOGYL/CYCLOPENT 1% PER DROP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
25000502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
CYCLOGYL/CYCLOPENT 1% PER DROP
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
25000502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
CYCLOPHOSPHAMIDE 5mg(1gmMDV)
|
Facility
|
OP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem Medicaid |
$137.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Cash Price |
$199.60
|
| Rate for Payer: Cigna Commercial |
$331.34
|
| Rate for Payer: First Health Commercial |
$379.25
|
| Rate for Payer: Humana Commercial |
$339.33
|
| Rate for Payer: Humana KY Medicaid |
$137.29
|
| Rate for Payer: Kentucky WC Medicaid |
$138.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$327.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$294.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$351.30
|
| Rate for Payer: Ohio Health Group HMO |
$299.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.76
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5mg(1gmMDV)
|
Facility
|
IP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Cash Price |
$199.60
|
| Rate for Payer: Cigna Commercial |
$331.34
|
| Rate for Payer: First Health Commercial |
$379.25
|
| Rate for Payer: Humana Commercial |
$339.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$327.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$294.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$351.30
|
| Rate for Payer: Ohio Health Group HMO |
$299.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.76
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5MG (1GM SDV)
|
Facility
|
OP
|
$3,053.96
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25003769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$397.01 |
| Max. Negotiated Rate |
$2,931.80 |
| Rate for Payer: United Healthcare All Payer |
$2,687.48
|
| Rate for Payer: Aetna Commercial |
$2,351.55
|
| Rate for Payer: Anthem Medicaid |
$1,050.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,382.09
|
| Rate for Payer: Cash Price |
$1,526.98
|
| Rate for Payer: Cigna Commercial |
$2,534.79
|
| Rate for Payer: First Health Commercial |
$2,901.26
|
| Rate for Payer: Humana Commercial |
$2,595.87
|
| Rate for Payer: Humana KY Medicaid |
$1,050.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,060.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,504.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,253.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$916.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,071.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,687.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,290.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$397.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$946.73
|
| Rate for Payer: PHCS Commercial |
$2,931.80
|
|
|
CYCLOPHOSPHAMIDE 5MG (1GM SDV)
|
Facility
|
IP
|
$3,053.96
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25003769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$397.01 |
| Max. Negotiated Rate |
$2,931.80 |
| Rate for Payer: Aetna Commercial |
$2,351.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,382.09
|
| Rate for Payer: Cash Price |
$1,526.98
|
| Rate for Payer: Cigna Commercial |
$2,534.79
|
| Rate for Payer: First Health Commercial |
$2,901.26
|
| Rate for Payer: Humana Commercial |
$2,595.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,504.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,253.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$916.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,687.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,290.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$397.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$946.73
|
| Rate for Payer: PHCS Commercial |
$2,931.80
|
| Rate for Payer: United Healthcare All Payer |
$2,687.48
|
|
|
CYCLOPHOSPHAMIDE 5mg(2gmMDV)
|
Facility
|
IP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Cash Price |
$199.60
|
| Rate for Payer: Cigna Commercial |
$331.34
|
| Rate for Payer: First Health Commercial |
$379.25
|
| Rate for Payer: Humana Commercial |
$339.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$327.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$294.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$351.30
|
| Rate for Payer: Ohio Health Group HMO |
$299.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.76
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5mg(2gmMDV)
|
Facility
|
OP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem Medicaid |
$137.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Cash Price |
$199.60
|
| Rate for Payer: Cigna Commercial |
$331.34
|
| Rate for Payer: First Health Commercial |
$379.25
|
| Rate for Payer: Humana Commercial |
$339.33
|
| Rate for Payer: Humana KY Medicaid |
$137.29
|
| Rate for Payer: Kentucky WC Medicaid |
$138.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$327.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$294.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$351.30
|
| Rate for Payer: Ohio Health Group HMO |
$299.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.76
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5mg(500mgMDV)
|
Facility
|
OP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem Medicaid |
$137.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Cash Price |
$199.60
|
| Rate for Payer: Cigna Commercial |
$331.34
|
| Rate for Payer: First Health Commercial |
$379.25
|
| Rate for Payer: Humana Commercial |
$339.33
|
| Rate for Payer: Humana KY Medicaid |
$137.29
|
| Rate for Payer: Kentucky WC Medicaid |
$138.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$327.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$294.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$351.30
|
| Rate for Payer: Ohio Health Group HMO |
$299.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.76
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5mg(500mgMDV)
|
Facility
|
IP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Cash Price |
$199.60
|
| Rate for Payer: Cigna Commercial |
$331.34
|
| Rate for Payer: First Health Commercial |
$379.25
|
| Rate for Payer: Humana Commercial |
$339.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$327.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$294.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$351.30
|
| Rate for Payer: Ohio Health Group HMO |
$299.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.76
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5MG(500mgSDV)
|
Facility
|
IP
|
$1,527.04
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25002587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.52 |
| Max. Negotiated Rate |
$1,465.96 |
| Rate for Payer: Aetna Commercial |
$1,175.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,191.09
|
| Rate for Payer: Cash Price |
$763.52
|
| Rate for Payer: Cigna Commercial |
$1,267.44
|
| Rate for Payer: First Health Commercial |
$1,450.69
|
| Rate for Payer: Humana Commercial |
$1,297.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,252.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,126.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$458.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,343.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,145.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$473.38
|
| Rate for Payer: PHCS Commercial |
$1,465.96
|
| Rate for Payer: United Healthcare All Payer |
$1,343.80
|
|
|
CYCLOPHOSPHAMIDE 5MG(500mgSDV)
|
Facility
|
OP
|
$1,527.04
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25002587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.52 |
| Max. Negotiated Rate |
$1,465.96 |
| Rate for Payer: Aetna Commercial |
$1,175.82
|
| Rate for Payer: Anthem Medicaid |
$525.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,191.09
|
| Rate for Payer: Cash Price |
$763.52
|
| Rate for Payer: Cigna Commercial |
$1,267.44
|
| Rate for Payer: First Health Commercial |
$1,450.69
|
| Rate for Payer: Humana Commercial |
$1,297.98
|
| Rate for Payer: Humana KY Medicaid |
$525.15
|
| Rate for Payer: Kentucky WC Medicaid |
$530.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,252.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,126.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$458.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$535.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,343.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,145.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$473.38
|
| Rate for Payer: PHCS Commercial |
$1,465.96
|
| Rate for Payer: United Healthcare All Payer |
$1,343.80
|
|
|
CYKLOKAPRON 100MG/ML AMP 10ML
|
Facility
|
OP
|
$112.50
|
|
|
Service Code
|
NDC 81284061100
|
| Hospital Charge Code |
25002976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.62 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$86.62
|
| Rate for Payer: Anthem Medicaid |
$38.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.75
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Cigna Commercial |
$93.38
|
| Rate for Payer: First Health Commercial |
$106.88
|
| Rate for Payer: Humana Commercial |
$95.62
|
| Rate for Payer: Humana KY Medicaid |
$38.69
|
| Rate for Payer: Kentucky WC Medicaid |
$39.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.00
|
| Rate for Payer: Ohio Health Group HMO |
$84.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.88
|
| Rate for Payer: PHCS Commercial |
$108.00
|
| Rate for Payer: United Healthcare All Payer |
$99.00
|
|
|
CYKLOKAPRON 100MG/ML AMP 10ML
|
Facility
|
IP
|
$112.50
|
|
|
Service Code
|
NDC 81284061100
|
| Hospital Charge Code |
25002976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.62 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$86.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.75
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Cigna Commercial |
$93.38
|
| Rate for Payer: First Health Commercial |
$106.88
|
| Rate for Payer: Humana Commercial |
$95.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.00
|
| Rate for Payer: Ohio Health Group HMO |
$84.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.88
|
| Rate for Payer: PHCS Commercial |
$108.00
|
| Rate for Payer: United Healthcare All Payer |
$99.00
|
|
|
CYMBALTA 60 MG CAPSULE
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 60687074501
|
| Hospital Charge Code |
25002977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna Commercial |
$7.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.49
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.97
|
| Rate for Payer: First Health Commercial |
$9.12
|
| Rate for Payer: Humana Commercial |
$8.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.45
|
| Rate for Payer: Ohio Health Group HMO |
$7.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$9.22
|
| Rate for Payer: United Healthcare All Payer |
$8.45
|
|
|
CYMBALTA 60 MG CAPSULE
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 60687074501
|
| Hospital Charge Code |
25002977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna Commercial |
$7.39
|
| Rate for Payer: Anthem Medicaid |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.49
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.97
|
| Rate for Payer: First Health Commercial |
$9.12
|
| Rate for Payer: Humana Commercial |
$8.16
|
| Rate for Payer: Humana KY Medicaid |
$3.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.45
|
| Rate for Payer: Ohio Health Group HMO |
$7.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$9.22
|
| Rate for Payer: United Healthcare All Payer |
$8.45
|
|
|
CYMBALTA(DULOXETINE)20MG CAP
|
Facility
|
IP
|
$9.77
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
25000505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Cigna Commercial |
$8.11
|
| Rate for Payer: First Health Commercial |
$9.28
|
| Rate for Payer: Humana Commercial |
$8.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.60
|
| Rate for Payer: Ohio Health Group HMO |
$7.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$9.38
|
| Rate for Payer: United Healthcare All Payer |
$8.60
|
|
|
CYMBALTA(DULOXETINE)20MG CAP
|
Facility
|
OP
|
$9.77
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
25000505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Anthem Medicaid |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Cigna Commercial |
$8.11
|
| Rate for Payer: First Health Commercial |
$9.28
|
| Rate for Payer: Humana Commercial |
$8.30
|
| Rate for Payer: Humana KY Medicaid |
$3.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.60
|
| Rate for Payer: Ohio Health Group HMO |
$7.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$9.38
|
| Rate for Payer: United Healthcare All Payer |
$8.60
|
|
|
CYMBALTA (DULOXETINE) 30 MGCAP
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 51991074790
|
| Hospital Charge Code |
25000504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
|
|
CYMBALTA (DULOXETINE) 30 MGCAP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 51991074790
|
| Hospital Charge Code |
25000504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
CYP3A4 GENE COMMON VARIANTS
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS 81230
|
| Hospital Charge Code |
30002007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.36
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
CYP3A4 GENE COMMON VARIANTS
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS 81230
|
| Hospital Charge Code |
30002007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$244.73 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem Medicaid |
$174.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$174.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$244.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$174.81
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Humana KY Medicaid |
$174.81
|
| Rate for Payer: Humana Medicare Advantage |
$174.81
|
| Rate for Payer: Kentucky WC Medicaid |
$176.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$209.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
