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All Charges

Charge

Type

Setting

Price

ZONISAMIDE 100 MG CAPSULE

Facility

IP

$4.14

Service Code	NDC 50268081611
Hospital Charge Code	27780
Hospital Revenue Code	637
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.73
Rate for Payer: Aetna Commercial	$3.52
Rate for Payer: Aetna New Business (MI Preferred)	$2.69
Rate for Payer: Cash Price	$3.31
Rate for Payer: Cofinity Commercial	$2.90
Rate for Payer: Cofinity Commercial	$3.56
Rate for Payer: Cofinity Medicare Advantage	$2.90
Rate for Payer: Encore Health Key Benefits Commercial	$3.31
Rate for Payer: Healthscope Commercial	$3.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.52
Rate for Payer: PHP Commercial	$3.52
Rate for Payer: Priority Health Cigna Priority Health	$2.69
Rate for Payer: Priority Health SBD	$2.61

ZONISAMIDE 100 MG CAPSULE

Facility

IP

$247.20

Service Code	NDC 60687023001
Hospital Charge Code	27780
Hospital Revenue Code	637
Min. Negotiated Rate	$155.74
Max. Negotiated Rate	$222.48
Rate for Payer: Aetna Commercial	$210.12
Rate for Payer: Aetna New Business (MI Preferred)	$160.68
Rate for Payer: Cash Price	$197.76
Rate for Payer: Cofinity Commercial	$173.04
Rate for Payer: Cofinity Commercial	$212.59
Rate for Payer: Cofinity Medicare Advantage	$173.04
Rate for Payer: Encore Health Key Benefits Commercial	$197.76
Rate for Payer: Healthscope Commercial	$222.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$210.12
Rate for Payer: PHP Commercial	$210.12
Rate for Payer: Priority Health Cigna Priority Health	$160.68
Rate for Payer: Priority Health SBD	$155.74

ZONISAMIDE 100 MG CAPSULE

Facility

IP

$2.48

Service Code	NDC 60687023011
Hospital Charge Code	27780
Hospital Revenue Code	637
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.23
Rate for Payer: Aetna Commercial	$2.11
Rate for Payer: Aetna New Business (MI Preferred)	$1.61
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cofinity Commercial	$1.74
Rate for Payer: Cofinity Commercial	$2.13
Rate for Payer: Cofinity Medicare Advantage	$1.74
Rate for Payer: Encore Health Key Benefits Commercial	$1.98
Rate for Payer: Healthscope Commercial	$2.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.11
Rate for Payer: PHP Commercial	$2.11
Rate for Payer: Priority Health Cigna Priority Health	$1.61
Rate for Payer: Priority Health SBD	$1.56

ZONISAMIDE 100 MG CAPSULE

Facility

IP

$324.90

Service Code	NDC 69097086107
Hospital Charge Code	27780
Hospital Revenue Code	637
Min. Negotiated Rate	$204.69
Max. Negotiated Rate	$292.41
Rate for Payer: Aetna Commercial	$276.17
Rate for Payer: Aetna New Business (MI Preferred)	$211.19
Rate for Payer: Cash Price	$259.92
Rate for Payer: Cofinity Commercial	$227.43
Rate for Payer: Cofinity Commercial	$279.41
Rate for Payer: Cofinity Medicare Advantage	$227.43
Rate for Payer: Encore Health Key Benefits Commercial	$259.92
Rate for Payer: Healthscope Commercial	$292.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$276.17
Rate for Payer: PHP Commercial	$276.17
Rate for Payer: Priority Health Cigna Priority Health	$211.19
Rate for Payer: Priority Health SBD	$204.69

ZONISAMIDE 100 MG CAPSULE

Facility

IP

$324.90

Service Code	NDC 68462013001
Hospital Charge Code	27780
Hospital Revenue Code	637
Min. Negotiated Rate	$204.69
Max. Negotiated Rate	$292.41
Rate for Payer: Aetna Commercial	$276.17
Rate for Payer: Aetna New Business (MI Preferred)	$211.19
Rate for Payer: Cash Price	$259.92
Rate for Payer: Cofinity Commercial	$227.43
Rate for Payer: Cofinity Commercial	$279.41
Rate for Payer: Cofinity Medicare Advantage	$227.43
Rate for Payer: Encore Health Key Benefits Commercial	$259.92
Rate for Payer: Healthscope Commercial	$292.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$276.17
Rate for Payer: PHP Commercial	$276.17
Rate for Payer: Priority Health Cigna Priority Health	$211.19
Rate for Payer: Priority Health SBD	$204.69