|
CYCLOPHOSPHAMIDE 5mg(500mgMDV)
|
Facility
|
OP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004196
|
|
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(500mgMDV)
|
Facility
|
IP
|
$399.21
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25004196
|
|
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
|
|
|
CYCLOPHOSPHAMIDE 5MG(500mgSDV)
|
Facility
|
IP
|
$1,527.04
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
25002587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$458.11 |
| 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 |
$1,221.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,328.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,053.66
|
| 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 |
$0.62 |
| 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 Medicare Advantage/PPO |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,191.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$763.52
|
| 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: Humana Medicare Advantage |
$0.62
|
| 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 |
$0.74
|
| 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 |
$1,221.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,328.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,053.66
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
25002976
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$33.75 |
| 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 |
$83.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.47
|
| 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 |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.62
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
25002976
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$33.75 |
| 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 |
$83.03
|
| 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 |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.62
|
| 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 |
$2.88 |
| 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 |
$7.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.62
|
| 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 |
$2.88 |
| 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 |
$7.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.62
|
| Rate for Payer: PHCS Commercial |
$9.22
|
| Rate for Payer: United Healthcare All Payer |
$8.45
|
|
|
CYMBALTA(DULOXETINE)20MG CAP
|
Facility
|
OP
|
$9.77
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
25000505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.93 |
| 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 |
$7.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.74
|
| Rate for Payer: PHCS Commercial |
$9.38
|
| Rate for Payer: United Healthcare All Payer |
$8.60
|
|
|
CYMBALTA(DULOXETINE)20MG CAP
|
Facility
|
IP
|
$9.77
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
25000505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.93 |
| 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 |
$7.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.74
|
| 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 |
$1.35 |
| 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 |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| 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 |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
CYMBALTA (DULOXETINE) 30 MGCAP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 51991074790
|
| Hospital Charge Code |
25000504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| 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 |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| 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 |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
CYP3A4 GENE COMMON VARIANTS
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS 81230
|
| Hospital Charge Code |
30002007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$128.34 |
| 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 |
$148.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.34
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
CYP3A4 GENE COMMON VARIANTS
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS 81230
|
| Hospital Charge Code |
30002007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.80 |
| 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 |
$148.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.34
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
CY PREP CONCENTRATE TECHNIQ
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30002033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$88.80 |
| Max. Negotiated Rate |
$284.16 |
| Rate for Payer: Aetna Commercial |
$227.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.69
|
| Rate for Payer: Cash Price |
$148.00
|
| Rate for Payer: Cigna Commercial |
$245.68
|
| Rate for Payer: First Health Commercial |
$281.20
|
| Rate for Payer: Humana Commercial |
$251.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$242.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$218.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$260.48
|
| Rate for Payer: Ohio Health Group HMO |
$222.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.24
|
| Rate for Payer: PHCS Commercial |
$284.16
|
| Rate for Payer: United Healthcare All Payer |
$260.48
|
|
|
CY PREP CONCENTRATE TECHNIQ
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30002033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$177.60 |
| Rate for Payer: Aetna Commercial |
$109.03
|
| Rate for Payer: Ambetter Exchange |
$63.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.88
|
| Rate for Payer: Cash Price |
$148.00
|
| Rate for Payer: Cash Price |
$148.00
|
| Rate for Payer: Cigna Commercial |
$44.28
|
| Rate for Payer: Healthspan PPO |
$103.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.23
|
| Rate for Payer: Multiplan PHCS |
$177.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.20
|
| Rate for Payer: UHCCP Medicaid |
$103.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.23
|
|
|
CY PREP CONCENTRATE TECHNIQ
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30002033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$284.16 |
| Rate for Payer: Aetna Commercial |
$227.92
|
| Rate for Payer: Anthem Medicaid |
$36.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.27
|
| Rate for Payer: Cash Price |
$148.00
|
| Rate for Payer: Cash Price |
$148.00
|
| Rate for Payer: Cigna Commercial |
$245.68
|
| Rate for Payer: First Health Commercial |
$281.20
|
| Rate for Payer: Humana Commercial |
$251.60
|
| Rate for Payer: Humana KY Medicaid |
$36.27
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$36.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$242.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$218.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$260.48
|
| Rate for Payer: Ohio Health Group HMO |
$222.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.24
|
| Rate for Payer: PHCS Commercial |
$284.16
|
| Rate for Payer: United Healthcare All Payer |
$260.48
|
|
|
CY PREP CONCENTRATE TECHNIQ (P
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
300P2033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$109.03 |
| Rate for Payer: Aetna Commercial |
$109.03
|
| Rate for Payer: Ambetter Exchange |
$63.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.88
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$44.28
|
| Rate for Payer: Healthspan PPO |
$103.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.23
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.20
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.23
|
|
|
CY PREP CONCENTRATE TECHNIQ (T
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
300T2033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$75.30 |
| Max. Negotiated Rate |
$240.96 |
| Rate for Payer: Aetna Commercial |
$193.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$201.55
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cigna Commercial |
$208.33
|
| Rate for Payer: First Health Commercial |
$238.45
|
| Rate for Payer: Humana Commercial |
$213.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.88
|
| Rate for Payer: Ohio Health Group HMO |
$188.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.19
|
| Rate for Payer: PHCS Commercial |
$240.96
|
| Rate for Payer: United Healthcare All Payer |
$220.88
|
|
|
CY PREP CONCENTRATE TECHNIQ (T
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
300T2033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$240.96 |
| Rate for Payer: Aetna Commercial |
$193.27
|
| Rate for Payer: Anthem Medicaid |
$36.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$201.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.27
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cigna Commercial |
$208.33
|
| Rate for Payer: First Health Commercial |
$238.45
|
| Rate for Payer: Humana Commercial |
$213.35
|
| Rate for Payer: Humana KY Medicaid |
$36.27
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$36.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.88
|
| Rate for Payer: Ohio Health Group HMO |
$188.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.19
|
| Rate for Payer: PHCS Commercial |
$240.96
|
| Rate for Payer: United Healthcare All Payer |
$220.88
|
|
|
CY PREP CONCENTRATION TECHNIQ
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30001417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem Medicaid |
$36.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.27
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Humana KY Medicaid |
$36.27
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$36.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.60
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
CY PREP CONCENTRATION TECHNIQ
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30001417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.72
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.60
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
CY PREP CONCENTRATION TECHNIQ
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30001417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$109.03
|
| Rate for Payer: Ambetter Exchange |
$63.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.88
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$44.28
|
| Rate for Payer: Healthspan PPO |
$103.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.23
|
| Rate for Payer: Multiplan PHCS |
$144.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.20
|
| Rate for Payer: UHCCP Medicaid |
$84.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.23
|
|
|
CYRAMZA 5MG (100MG/10ML)VIAL
|
Facility
|
IP
|
$8,018.91
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,405.67 |
| Max. Negotiated Rate |
$7,698.15 |
| Rate for Payer: Aetna Commercial |
$6,174.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.75
|
| Rate for Payer: Cash Price |
$4,009.46
|
| Rate for Payer: Cigna Commercial |
$6,655.70
|
| Rate for Payer: First Health Commercial |
$7,617.96
|
| Rate for Payer: Humana Commercial |
$6,816.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,533.05
|
| Rate for Payer: PHCS Commercial |
$7,698.15
|
| Rate for Payer: United Healthcare All Payer |
$7,056.64
|
|
|
CYRAMZA 5MG (100MG/10ML)VIAL
|
Facility
|
OP
|
$8,018.91
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.45 |
| Max. Negotiated Rate |
$7,698.15 |
| Rate for Payer: Aetna Commercial |
$6,174.56
|
| Rate for Payer: Anthem Medicaid |
$2,757.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$74.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$104.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$100.51
|
| Rate for Payer: Cash Price |
$4,009.46
|
| Rate for Payer: Cash Price |
$4,009.46
|
| Rate for Payer: Cigna Commercial |
$6,655.70
|
| Rate for Payer: First Health Commercial |
$7,617.96
|
| Rate for Payer: Humana Commercial |
$6,816.07
|
| Rate for Payer: Humana KY Medicaid |
$2,757.70
|
| Rate for Payer: Humana Medicare Advantage |
$74.45
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$89.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,813.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,533.05
|
| Rate for Payer: PHCS Commercial |
$7,698.15
|
| Rate for Payer: United Healthcare All Payer |
$7,056.64
|
|
