|
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK
|
Facility
OP
|
$103.24
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
167580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$92.92 |
| Rate for Payer: Aetna Commercial |
$87.75
|
| Rate for Payer: Aetna Commercial |
$146.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.11
|
| Rate for Payer: BCBS Complete |
$41.30
|
| Rate for Payer: BCBS Complete |
$69.06
|
| Rate for Payer: BCBS Trust/PPO |
$21.33
|
| Rate for Payer: BCBS Trust/PPO |
$21.33
|
| Rate for Payer: Cash Price |
$138.13
|
| Rate for Payer: Cash Price |
$82.59
|
| Rate for Payer: Cash Price |
$82.59
|
| Rate for Payer: Cash Price |
$138.13
|
| Rate for Payer: Cofinity Commercial |
$148.49
|
| Rate for Payer: Cofinity Commercial |
$88.79
|
| Rate for Payer: Cofinity Commercial |
$72.27
|
| Rate for Payer: Cofinity Commercial |
$120.86
|
| Rate for Payer: Healthscope Commercial |
$92.92
|
| Rate for Payer: Healthscope Commercial |
$155.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$146.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.75
|
| Rate for Payer: PHP Commercial |
$146.76
|
| Rate for Payer: PHP Commercial |
$87.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.86
|
| Rate for Payer: Priority Health SBD |
$108.78
|
| Rate for Payer: Priority Health SBD |
$65.04
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$116.44
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
35640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.36 |
| Max. Negotiated Rate |
$104.80 |
| Rate for Payer: Aetna Commercial |
$98.97
|
| Rate for Payer: Aetna Commercial |
$283.59
|
| Rate for Payer: Aetna Commercial |
$319.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.69
|
| Rate for Payer: Cash Price |
$300.78
|
| Rate for Payer: Cash Price |
$93.15
|
| Rate for Payer: Cash Price |
$266.91
|
| Rate for Payer: Cofinity Commercial |
$286.93
|
| Rate for Payer: Cofinity Commercial |
$100.14
|
| Rate for Payer: Cofinity Commercial |
$81.51
|
| Rate for Payer: Cofinity Commercial |
$323.33
|
| Rate for Payer: Cofinity Commercial |
$263.18
|
| Rate for Payer: Cofinity Commercial |
$233.55
|
| Rate for Payer: Healthscope Commercial |
$300.28
|
| Rate for Payer: Healthscope Commercial |
$104.80
|
| Rate for Payer: Healthscope Commercial |
$338.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$319.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$283.59
|
| Rate for Payer: PHP Commercial |
$319.57
|
| Rate for Payer: PHP Commercial |
$283.59
|
| Rate for Payer: PHP Commercial |
$98.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.18
|
| Rate for Payer: Priority Health SBD |
$73.36
|
| Rate for Payer: Priority Health SBD |
$236.86
|
| Rate for Payer: Priority Health SBD |
$210.19
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
OP
|
$333.64
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
35640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$300.28 |
| Rate for Payer: Aetna Commercial |
$283.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.87
|
| Rate for Payer: BCBS Complete |
$133.46
|
| Rate for Payer: BCBS Trust/PPO |
$21.33
|
| Rate for Payer: Cash Price |
$266.91
|
| Rate for Payer: Cash Price |
$266.91
|
| Rate for Payer: Cofinity Commercial |
$233.55
|
| Rate for Payer: Cofinity Commercial |
$286.93
|
| Rate for Payer: Healthscope Commercial |
$300.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$283.59
|
| Rate for Payer: PHP Commercial |
$283.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.55
|
| Rate for Payer: Priority Health SBD |
$210.19
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK
|
Facility
IP
|
$387.22
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
81434
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.95 |
| Max. Negotiated Rate |
$348.50 |
| Rate for Payer: Aetna Commercial |
$329.14
|
| Rate for Payer: Aetna Commercial |
$172.35
|
| Rate for Payer: Aetna Commercial |
$3,606.45
|
| Rate for Payer: Aetna Commercial |
$238.61
|
| Rate for Payer: Aetna Commercial |
$389.69
|
| Rate for Payer: Aetna Commercial |
$186.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,757.87
|
| Rate for Payer: Cash Price |
$175.95
|
| Rate for Payer: Cash Price |
$309.78
|
| Rate for Payer: Cash Price |
$3,394.30
|
| Rate for Payer: Cash Price |
$162.22
|
| Rate for Payer: Cash Price |
$224.58
|
| Rate for Payer: Cash Price |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$2,970.02
|
| Rate for Payer: Cofinity Commercial |
$333.01
|
| Rate for Payer: Cofinity Commercial |
$141.94
|
| Rate for Payer: Cofinity Commercial |
$271.05
|
| Rate for Payer: Cofinity Commercial |
$394.28
|
| Rate for Payer: Cofinity Commercial |
$196.50
|
| Rate for Payer: Cofinity Commercial |
$241.42
|
| Rate for Payer: Cofinity Commercial |
$153.96
|
| Rate for Payer: Cofinity Commercial |
$189.15
|
| Rate for Payer: Cofinity Commercial |
$320.92
|
| Rate for Payer: Cofinity Commercial |
$174.38
|
| Rate for Payer: Cofinity Commercial |
$3,648.88
|
| Rate for Payer: Healthscope Commercial |
$182.49
|
| Rate for Payer: Healthscope Commercial |
$197.95
|
| Rate for Payer: Healthscope Commercial |
$252.65
|
| Rate for Payer: Healthscope Commercial |
$348.50
|
| Rate for Payer: Healthscope Commercial |
$3,818.59
|
| Rate for Payer: Healthscope Commercial |
$412.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$238.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$329.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,606.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$389.69
|
| Rate for Payer: PHP Commercial |
$3,606.45
|
| Rate for Payer: PHP Commercial |
$172.35
|
| Rate for Payer: PHP Commercial |
$389.69
|
| Rate for Payer: PHP Commercial |
$329.14
|
| Rate for Payer: PHP Commercial |
$186.95
|
| Rate for Payer: PHP Commercial |
$238.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,970.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.94
|
| Rate for Payer: Priority Health SBD |
$2,673.01
|
| Rate for Payer: Priority Health SBD |
$243.95
|
| Rate for Payer: Priority Health SBD |
$127.75
|
| Rate for Payer: Priority Health SBD |
$288.83
|
| Rate for Payer: Priority Health SBD |
$138.56
|
| Rate for Payer: Priority Health SBD |
$176.85
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK
|
Facility
OP
|
$219.94
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
81434
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$197.95 |
| Rate for Payer: Aetna Commercial |
$186.95
|
| Rate for Payer: Aetna Commercial |
$137.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.26
|
| Rate for Payer: BCBS Complete |
$64.78
|
| Rate for Payer: BCBS Complete |
$87.98
|
| Rate for Payer: BCBS Trust/PPO |
$21.33
|
| Rate for Payer: BCBS Trust/PPO |
$21.33
|
| Rate for Payer: Cash Price |
$129.55
|
| Rate for Payer: Cash Price |
$175.95
|
| Rate for Payer: Cash Price |
$175.95
|
| Rate for Payer: Cash Price |
$129.55
|
| Rate for Payer: Cofinity Commercial |
$153.96
|
| Rate for Payer: Cofinity Commercial |
$189.15
|
| Rate for Payer: Cofinity Commercial |
$113.36
|
| Rate for Payer: Cofinity Commercial |
$139.27
|
| Rate for Payer: Healthscope Commercial |
$197.95
|
| Rate for Payer: Healthscope Commercial |
$145.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.65
|
| Rate for Payer: PHP Commercial |
$137.65
|
| Rate for Payer: PHP Commercial |
$186.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.96
|
| Rate for Payer: Priority Health SBD |
$102.02
|
| Rate for Payer: Priority Health SBD |
$138.56
|
|
|
ZOLPIDEM 5 MG TABLET
|
Facility
IP
|
$113.75
|
|
|
Service Code
|
NDC 0781-5317-01
|
| Hospital Charge Code |
11701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.66 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna Commercial |
$96.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.94
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cofinity Commercial |
$79.62
|
| Rate for Payer: Cofinity Commercial |
$97.82
|
| Rate for Payer: Healthscope Commercial |
$102.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$96.69
|
| Rate for Payer: PHP Commercial |
$96.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.62
|
| Rate for Payer: Priority Health SBD |
$71.66
|
|
|
ZOLPIDEM 5 MG TABLET
|
Facility
IP
|
$11.03
|
|
|
Service Code
|
NDC 0904-6082-61
|
| Hospital Charge Code |
11701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$9.93 |
| Rate for Payer: Aetna Commercial |
$9.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.17
|
| Rate for Payer: Cash Price |
$8.82
|
| Rate for Payer: Cofinity Commercial |
$7.72
|
| Rate for Payer: Cofinity Commercial |
$9.49
|
| Rate for Payer: Healthscope Commercial |
$9.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.38
|
| Rate for Payer: PHP Commercial |
$9.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.72
|
| Rate for Payer: Priority Health SBD |
$6.95
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$2.48
|
|
|
Service Code
|
NDC 60687-230-11
|
| 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: Healthscope Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.11
|
| Rate for Payer: PHP Commercial |
$2.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health SBD |
$1.56
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$203.30
|
|
|
Service Code
|
NDC 50268-816-15
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.08 |
| Max. Negotiated Rate |
$182.97 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.14
|
| Rate for Payer: Cash Price |
$162.64
|
| Rate for Payer: Cofinity Commercial |
$142.31
|
| Rate for Payer: Cofinity Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$182.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.80
|
| Rate for Payer: PHP Commercial |
$172.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.31
|
| Rate for Payer: Priority Health SBD |
$128.08
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$324.90
|
|
|
Service Code
|
NDC 69097-861-07
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.69 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.43
|
| Rate for Payer: Priority Health SBD |
$204.69
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$324.90
|
|
|
Service Code
|
NDC 68462-130-01
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.69 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.43
|
| Rate for Payer: Priority Health SBD |
$204.69
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$4.07
|
|
|
Service Code
|
NDC 50268-816-11
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.65
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Cofinity Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$3.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.46
|
| Rate for Payer: PHP Commercial |
$3.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.85
|
| Rate for Payer: Priority Health SBD |
$2.56
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$247.20
|
|
|
Service Code
|
NDC 60687-230-01
|
| 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: Healthscope Commercial |
$222.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$210.12
|
| Rate for Payer: PHP Commercial |
$210.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$173.04
|
| Rate for Payer: Priority Health SBD |
$155.74
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
IP
|
$7,298.25
|
|
|
Service Code
|
NDC 59212-680-10
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,597.90 |
| Max. Negotiated Rate |
$6,568.42 |
| Rate for Payer: Aetna Commercial |
$6,203.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,743.86
|
| Rate for Payer: Cash Price |
$5,838.60
|
| Rate for Payer: Cofinity Commercial |
$5,108.78
|
| Rate for Payer: Cofinity Commercial |
$6,276.50
|
| Rate for Payer: Healthscope Commercial |
$6,568.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,203.51
|
| Rate for Payer: PHP Commercial |
$6,203.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,108.78
|
| Rate for Payer: Priority Health SBD |
$4,597.90
|
|
