|
CYANIDE(SOD.THI/SONI)ANTIDSKIT
|
Facility
|
IP
|
$663.00
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
25002975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$636.48 |
| Rate for Payer: Aetna Commercial |
$510.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$517.14
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cigna Commercial |
$550.29
|
| Rate for Payer: First Health Commercial |
$629.85
|
| Rate for Payer: Humana Commercial |
$563.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$543.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$489.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$583.44
|
| Rate for Payer: Ohio Health Group HMO |
$497.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$576.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$457.47
|
| Rate for Payer: PHCS Commercial |
$636.48
|
| Rate for Payer: United Healthcare All Payer |
$583.44
|
|
|
CYANIDE(SOD.THI/SONI)ANTIDSKIT
|
Facility
|
OP
|
$663.00
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
25002975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$636.48 |
| Rate for Payer: Aetna Commercial |
$510.51
|
| Rate for Payer: Anthem Medicaid |
$228.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$517.14
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cigna Commercial |
$550.29
|
| Rate for Payer: First Health Commercial |
$629.85
|
| Rate for Payer: Humana Commercial |
$563.55
|
| Rate for Payer: Humana KY Medicaid |
$228.01
|
| Rate for Payer: Kentucky WC Medicaid |
$230.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$543.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$489.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$232.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$583.44
|
| Rate for Payer: Ohio Health Group HMO |
$497.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$576.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$457.47
|
| Rate for Payer: PHCS Commercial |
$636.48
|
| Rate for Payer: United Healthcare All Payer |
$583.44
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
IP
|
$113.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
63600067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.17 |
| 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 |
$91.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.60
|
| 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 |
$34.17 |
| 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 |
$91.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.60
|
| Rate for Payer: PHCS Commercial |
$109.35
|
| Rate for Payer: United Healthcare All Payer |
$100.24
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
IP
|
$113.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
636T0067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.17 |
| 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 |
$91.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.60
|
| 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 |
63600067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.17 |
| 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 |
$91.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.60
|
| Rate for Payer: PHCS Commercial |
$109.35
|
| Rate for Payer: United Healthcare All Payer |
$100.24
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Professional
|
Both
|
$113.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
63600067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$68.35 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: Ambetter Exchange |
$0.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.14
|
| Rate for Payer: Cash Price |
$56.95
|
| Rate for Payer: Cash Price |
$56.95
|
| Rate for Payer: Healthspan PPO |
$0.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Multiplan PHCS |
$68.35
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.24
|
| Rate for Payer: UHCCP Medicaid |
$39.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.95
|
|
|
CYANOCOBALAMIN 1000MCG/1ML
|
Facility
|
IP
|
$113.91
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
25002426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.17 |
| 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 |
$91.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.60
|
| 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 |
636T0067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.17 |
| 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 |
$91.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.60
|
| Rate for Payer: PHCS Commercial |
$109.35
|
| Rate for Payer: United Healthcare All Payer |
$100.24
|
|
|
CYCLOGYL 0.5% 15 ML (per Drop)
|
Facility
|
IP
|
$519.24
|
|
|
Service Code
|
NDC 65039515
|
| Hospital Charge Code |
25003966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.77 |
| Max. Negotiated Rate |
$498.47 |
| Rate for Payer: Aetna Commercial |
$399.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$405.01
|
| Rate for Payer: Cash Price |
$259.62
|
| Rate for Payer: Cigna Commercial |
$430.97
|
| Rate for Payer: First Health Commercial |
$493.28
|
| Rate for Payer: Humana Commercial |
$441.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.93
|
| Rate for Payer: Ohio Health Group HMO |
$389.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$415.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$358.28
|
| Rate for Payer: PHCS Commercial |
$498.47
|
| Rate for Payer: United Healthcare All Payer |
$456.93
|
|
|
CYCLOGYL 0.5% 15 ML (per Drop)
|
Facility
|
OP
|
$519.24
|
|
|
Service Code
|
NDC 65039515
|
| Hospital Charge Code |
25003966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.77 |
| Max. Negotiated Rate |
$498.47 |
| Rate for Payer: Aetna Commercial |
$399.81
|
| Rate for Payer: Anthem Medicaid |
$178.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$405.01
|
| Rate for Payer: Cash Price |
$259.62
|
| Rate for Payer: Cigna Commercial |
$430.97
|
| Rate for Payer: First Health Commercial |
$493.28
|
| Rate for Payer: Humana Commercial |
$441.35
|
| Rate for Payer: Humana KY Medicaid |
$178.57
|
| Rate for Payer: Kentucky WC Medicaid |
$180.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.93
|
| Rate for Payer: Ohio Health Group HMO |
$389.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$415.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$358.28
|
| Rate for Payer: PHCS Commercial |
$498.47
|
| Rate for Payer: United Healthcare All Payer |
$456.93
|
|
|
CYCLOGYL 1% 15 ML (per Drop)
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004420
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
CYCLOGYL 1% 15 ML (per Drop)
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004420
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem Medicaid |
$61.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Humana KY Medicaid |
$61.56
|
| Rate for Payer: Kentucky WC Medicaid |
$62.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
CYCLOGYL 2% 2 ML (per Drop)
|
Facility
|
OP
|
$197.37
|
|
|
Service Code
|
NDC 65039702
|
| Hospital Charge Code |
25003967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.21 |
| Max. Negotiated Rate |
$189.48 |
| Rate for Payer: Aetna Commercial |
$151.97
|
| Rate for Payer: Anthem Medicaid |
$67.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$153.95
|
| Rate for Payer: Cash Price |
$98.68
|
| Rate for Payer: Cigna Commercial |
$163.82
|
| Rate for Payer: First Health Commercial |
$187.50
|
| Rate for Payer: Humana Commercial |
$167.76
|
| Rate for Payer: Humana KY Medicaid |
$67.88
|
| Rate for Payer: Kentucky WC Medicaid |
$68.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$161.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$145.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$173.69
|
| Rate for Payer: Ohio Health Group HMO |
$148.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$171.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.19
|
| Rate for Payer: PHCS Commercial |
$189.48
|
| Rate for Payer: United Healthcare All Payer |
$173.69
|
|
|
CYCLOGYL 2% 2 ML (per Drop)
|
Facility
|
IP
|
$197.37
|
|
|
Service Code
|
NDC 65039702
|
| Hospital Charge Code |
25003967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.21 |
| Max. Negotiated Rate |
$189.48 |
| Rate for Payer: Aetna Commercial |
$151.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$153.95
|
| Rate for Payer: Cash Price |
$98.68
|
| Rate for Payer: Cigna Commercial |
$163.82
|
| Rate for Payer: First Health Commercial |
$187.50
|
| Rate for Payer: Humana Commercial |
$167.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$161.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$145.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$173.69
|
| Rate for Payer: Ohio Health Group HMO |
$148.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$171.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.19
|
| Rate for Payer: PHCS Commercial |
$189.48
|
| Rate for Payer: United Healthcare All Payer |
$173.69
|
|
|
CYCLOGYL 2% 5 ML (per Drop)
|
Facility
|
IP
|
$311.65
|
|
|
Service Code
|
NDC 65039705
|
| Hospital Charge Code |
25003968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.50 |
| Max. Negotiated Rate |
$299.18 |
| Rate for Payer: Aetna Commercial |
$239.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$243.09
|
| Rate for Payer: Cash Price |
$155.82
|
| Rate for Payer: Cigna Commercial |
$258.67
|
| Rate for Payer: First Health Commercial |
$296.07
|
| Rate for Payer: Humana Commercial |
$264.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$255.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$230.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$274.25
|
| Rate for Payer: Ohio Health Group HMO |
$233.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$215.04
|
| Rate for Payer: PHCS Commercial |
$299.18
|
| Rate for Payer: United Healthcare All Payer |
$274.25
|
|
|
CYCLOGYL 2% 5 ML (per Drop)
|
Facility
|
OP
|
$311.65
|
|
|
Service Code
|
NDC 65039705
|
| Hospital Charge Code |
25003968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.50 |
| Max. Negotiated Rate |
$299.18 |
| Rate for Payer: Aetna Commercial |
$239.97
|
| Rate for Payer: Anthem Medicaid |
$107.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$243.09
|
| Rate for Payer: Cash Price |
$155.82
|
| Rate for Payer: Cigna Commercial |
$258.67
|
| Rate for Payer: First Health Commercial |
$296.07
|
| Rate for Payer: Humana Commercial |
$264.90
|
| Rate for Payer: Humana KY Medicaid |
$107.18
|
| Rate for Payer: Kentucky WC Medicaid |
$108.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$255.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$230.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$109.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$274.25
|
| Rate for Payer: Ohio Health Group HMO |
$233.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$215.04
|
| Rate for Payer: PHCS Commercial |
$299.18
|
| Rate for Payer: United Healthcare All Payer |
$274.25
|
|
|
CYCLOGYL/CYCLOPENT 1% BOTTLE
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
25000502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.09 |
| Max. Negotiated Rate |
$83.47 |
| Rate for Payer: Aetna Commercial |
$66.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.82
|
| Rate for Payer: Cash Price |
$43.48
|
| Rate for Payer: Cigna Commercial |
$72.17
|
| Rate for Payer: First Health Commercial |
$82.60
|
| Rate for Payer: Humana Commercial |
$73.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.52
|
| Rate for Payer: Ohio Health Group HMO |
$65.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.00
|
| Rate for Payer: PHCS Commercial |
$83.47
|
| Rate for Payer: United Healthcare All Payer |
$76.52
|
|
|
CYCLOGYL/CYCLOPENT 1% BOTTLE
|
Facility
|
OP
|
$86.95
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
25000502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.09 |
| Max. Negotiated Rate |
$83.47 |
| Rate for Payer: Aetna Commercial |
$66.95
|
| Rate for Payer: Anthem Medicaid |
$29.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.82
|
| Rate for Payer: Cash Price |
$43.48
|
| Rate for Payer: Cigna Commercial |
$72.17
|
| Rate for Payer: First Health Commercial |
$82.60
|
| Rate for Payer: Humana Commercial |
$73.91
|
| Rate for Payer: Humana KY Medicaid |
$29.90
|
| Rate for Payer: Kentucky WC Medicaid |
$30.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.52
|
| Rate for Payer: Ohio Health Group HMO |
$65.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.00
|
| Rate for Payer: PHCS Commercial |
$83.47
|
| Rate for Payer: United Healthcare All Payer |
$76.52
|
|
|
CYCLOPHOSPHAMIDE 5mg(1gmMDV)
|
Facility
|
IP
|
$136.25
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.01
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
CYCLOPHOSPHAMIDE 5mg(1gmMDV)
|
Facility
|
OP
|
$136.25
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem Medicaid |
$46.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Humana KY Medicaid |
$46.86
|
| Rate for Payer: Humana Medicare Advantage |
$0.62
|
| Rate for Payer: Kentucky WC Medicaid |
$47.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.01
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
CYCLOPHOSPHAMIDE 5MG (1GM SDV)
|
Facility
|
OP
|
$3,053.96
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25003769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2,931.80 |
| Rate for Payer: Aetna Commercial |
$2,351.55
|
| Rate for Payer: Anthem Medicaid |
$1,050.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,382.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$1,526.98
|
| 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: Humana Medicare Advantage |
$0.62
|
| 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 |
$0.74
|
| 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 |
$2,443.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,656.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,107.23
|
| Rate for Payer: PHCS Commercial |
$2,931.80
|
| Rate for Payer: United Healthcare All Payer |
$2,687.48
|
|
|
CYCLOPHOSPHAMIDE 5MG (1GM SDV)
|
Facility
|
IP
|
$3,053.96
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25003769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$916.19 |
| 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 |
$2,443.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,656.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,107.23
|
| Rate for Payer: PHCS Commercial |
$2,931.80
|
| Rate for Payer: United Healthcare All Payer |
$2,687.48
|
|
|
CYCLOPHOSPHAMIDE 5mg(2gmMDV)
|
Facility
|
OP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$383.24 |
| Rate for Payer: Aetna Commercial |
$307.39
|
| Rate for Payer: Anthem Medicaid |
$137.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$311.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$199.60
|
| 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: Humana Medicare Advantage |
$0.62
|
| 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 |
$0.74
|
| 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 |
$319.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$347.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$275.45
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
|
CYCLOPHOSPHAMIDE 5mg(2gmMDV)
|
Facility
|
IP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.76 |
| 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 |
$319.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$347.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$275.45
|
| Rate for Payer: PHCS Commercial |
$383.24
|
| Rate for Payer: United Healthcare All Payer |
$351.30
|
|
