|
YERVOY 1mg (50mg Vial)
|
Facility
|
OP
|
$47,432.11
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
25003723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.42 |
| Max. Negotiated Rate |
$45,534.83 |
| Rate for Payer: Aetna Commercial |
$36,522.72
|
| Rate for Payer: Anthem Medicaid |
$16,311.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$172.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$36,997.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$241.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$232.77
|
| Rate for Payer: Cash Price |
$23,716.06
|
| Rate for Payer: Cash Price |
$23,716.06
|
| Rate for Payer: Cigna Commercial |
$39,368.65
|
| Rate for Payer: First Health Commercial |
$45,060.50
|
| Rate for Payer: Humana Commercial |
$40,317.29
|
| Rate for Payer: Humana KY Medicaid |
$16,311.90
|
| Rate for Payer: Humana Medicare Advantage |
$172.42
|
| Rate for Payer: Kentucky WC Medicaid |
$16,477.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$38,894.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35,004.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,639.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$41,740.26
|
| Rate for Payer: Ohio Health Group HMO |
$35,574.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,486.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,166.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,703.95
|
| Rate for Payer: PHCS Commercial |
$45,534.83
|
| Rate for Payer: United Healthcare All Payer |
$41,740.26
|
|
|
YOKE OSS REINFORCED
|
Facility
|
OP
|
$8,629.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,121.84 |
| Max. Negotiated Rate |
$8,284.34 |
| Rate for Payer: Aetna Commercial |
$6,644.73
|
| Rate for Payer: Anthem Medicaid |
$2,967.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,731.03
|
| Rate for Payer: Cash Price |
$4,314.76
|
| Rate for Payer: Cigna Commercial |
$7,162.50
|
| Rate for Payer: First Health Commercial |
$8,198.04
|
| Rate for Payer: Humana Commercial |
$7,335.09
|
| Rate for Payer: Humana KY Medicaid |
$2,967.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,997.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,076.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,368.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,588.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,027.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,593.98
|
| Rate for Payer: Ohio Health Group HMO |
$6,472.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,725.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,121.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,675.15
|
| Rate for Payer: PHCS Commercial |
$8,284.34
|
| Rate for Payer: United Healthcare All Payer |
$7,593.98
|
|
|
YOKE OSS REINFORCED
|
Facility
|
IP
|
$8,629.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,121.84 |
| Max. Negotiated Rate |
$8,284.34 |
| Rate for Payer: Aetna Commercial |
$6,644.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,731.03
|
| Rate for Payer: Cash Price |
$4,314.76
|
| Rate for Payer: Cigna Commercial |
$7,162.50
|
| Rate for Payer: First Health Commercial |
$8,198.04
|
| Rate for Payer: Humana Commercial |
$7,335.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,076.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,368.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,588.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,593.98
|
| Rate for Payer: Ohio Health Group HMO |
$6,472.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,725.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,121.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,675.15
|
| Rate for Payer: PHCS Commercial |
$8,284.34
|
| Rate for Payer: United Healthcare All Payer |
$7,593.98
|
|
|
Y-PLATE 5TH MET LT
|
Facility
|
OP
|
$8,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,132.69 |
| Max. Negotiated Rate |
$8,364.48 |
| Rate for Payer: Aetna Commercial |
$6,709.01
|
| Rate for Payer: Anthem Medicaid |
$2,996.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,796.14
|
| Rate for Payer: Cash Price |
$4,356.50
|
| Rate for Payer: Cigna Commercial |
$7,231.79
|
| Rate for Payer: First Health Commercial |
$8,277.35
|
| Rate for Payer: Humana Commercial |
$7,406.05
|
| Rate for Payer: Humana KY Medicaid |
$2,996.40
|
| Rate for Payer: Kentucky WC Medicaid |
$3,026.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,144.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,430.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,613.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,056.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,667.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,534.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,742.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,132.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,701.03
|
| Rate for Payer: PHCS Commercial |
$8,364.48
|
| Rate for Payer: United Healthcare All Payer |
$7,667.44
|
|
|
Y-PLATE 5TH MET LT
|
Facility
|
IP
|
$8,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,132.69 |
| Max. Negotiated Rate |
$8,364.48 |
| Rate for Payer: Aetna Commercial |
$6,709.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,796.14
|
| Rate for Payer: Cash Price |
$4,356.50
|
| Rate for Payer: Cigna Commercial |
$7,231.79
|
| Rate for Payer: First Health Commercial |
$8,277.35
|
| Rate for Payer: Humana Commercial |
$7,406.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,144.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,430.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,667.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,534.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,742.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,132.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,701.03
|
| Rate for Payer: PHCS Commercial |
$8,364.48
|
| Rate for Payer: United Healthcare All Payer |
$7,667.44
|
|
|
Y-PLATE 5TH MET RT
|
Facility
|
IP
|
$8,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,132.69 |
| Max. Negotiated Rate |
$8,364.48 |
| Rate for Payer: Aetna Commercial |
$6,709.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,796.14
|
| Rate for Payer: Cash Price |
$4,356.50
|
| Rate for Payer: Cigna Commercial |
$7,231.79
|
| Rate for Payer: First Health Commercial |
$8,277.35
|
| Rate for Payer: Humana Commercial |
$7,406.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,144.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,430.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,667.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,534.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,742.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,132.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,701.03
|
| Rate for Payer: PHCS Commercial |
$8,364.48
|
| Rate for Payer: United Healthcare All Payer |
$7,667.44
|
|
|
Y-PLATE 5TH MET RT
|
Facility
|
OP
|
$8,713.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,132.69 |
| Max. Negotiated Rate |
$8,364.48 |
| Rate for Payer: Aetna Commercial |
$6,709.01
|
| Rate for Payer: Anthem Medicaid |
$2,996.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,796.14
|
| Rate for Payer: Cash Price |
$4,356.50
|
| Rate for Payer: Cigna Commercial |
$7,231.79
|
| Rate for Payer: First Health Commercial |
$8,277.35
|
| Rate for Payer: Humana Commercial |
$7,406.05
|
| Rate for Payer: Humana KY Medicaid |
$2,996.40
|
| Rate for Payer: Kentucky WC Medicaid |
$3,026.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,144.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,430.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,613.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,056.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,667.44
|
| Rate for Payer: Ohio Health Group HMO |
$6,534.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,742.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,132.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,701.03
|
| Rate for Payer: PHCS Commercial |
$8,364.48
|
| Rate for Payer: United Healthcare All Payer |
$7,667.44
|
|
|
Y-TEC PROCEDURE PACK STD
|
Facility
|
OP
|
$2,029.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.77 |
| Max. Negotiated Rate |
$1,947.84 |
| Rate for Payer: Aetna Commercial |
$1,562.33
|
| Rate for Payer: Anthem Medicaid |
$697.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,582.62
|
| Rate for Payer: Cash Price |
$1,014.50
|
| Rate for Payer: Cigna Commercial |
$1,684.07
|
| Rate for Payer: First Health Commercial |
$1,927.55
|
| Rate for Payer: Humana Commercial |
$1,724.65
|
| Rate for Payer: Humana KY Medicaid |
$697.77
|
| Rate for Payer: Kentucky WC Medicaid |
$704.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,663.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,497.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$608.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$711.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,785.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,521.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$628.99
|
| Rate for Payer: PHCS Commercial |
$1,947.84
|
| Rate for Payer: United Healthcare All Payer |
$1,785.52
|
|
|
Y-TEC PROCEDURE PACK STD
|
Facility
|
IP
|
$2,029.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.77 |
| Max. Negotiated Rate |
$1,947.84 |
| Rate for Payer: Aetna Commercial |
$1,562.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,582.62
|
| Rate for Payer: Cash Price |
$1,014.50
|
| Rate for Payer: Cigna Commercial |
$1,684.07
|
| Rate for Payer: First Health Commercial |
$1,927.55
|
| Rate for Payer: Humana Commercial |
$1,724.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,663.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,497.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$608.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,785.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,521.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$628.99
|
| Rate for Payer: PHCS Commercial |
$1,947.84
|
| Rate for Payer: United Healthcare All Payer |
$1,785.52
|
|
|
YTTRIU 90 IBRITUMO TIUX PR DOS
|
Facility
|
IP
|
$63,605.00
|
|
|
Service Code
|
HCPCS A9543
|
| Hospital Charge Code |
34000058
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$8,268.65 |
| Max. Negotiated Rate |
$61,060.80 |
| Rate for Payer: Aetna Commercial |
$48,975.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49,611.90
|
| Rate for Payer: Cash Price |
$31,802.50
|
| Rate for Payer: Cigna Commercial |
$52,792.15
|
| Rate for Payer: First Health Commercial |
$60,424.75
|
| Rate for Payer: Humana Commercial |
$54,064.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52,156.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,940.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,081.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,972.40
|
| Rate for Payer: Ohio Health Group HMO |
$47,703.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,721.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,268.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,717.55
|
| Rate for Payer: PHCS Commercial |
$61,060.80
|
| Rate for Payer: United Healthcare All Payer |
$55,972.40
|
|
|
YTTRIU 90 IBRITUMO TIUX PR DOS
|
Facility
|
OP
|
$63,605.00
|
|
|
Service Code
|
HCPCS A9543
|
| Hospital Charge Code |
34000058
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$8,268.65 |
| Max. Negotiated Rate |
$91,667.21 |
| Rate for Payer: Aetna Commercial |
$48,975.85
|
| Rate for Payer: Anthem Medicaid |
$21,873.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65,476.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49,611.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$91,667.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$88,393.39
|
| Rate for Payer: Cash Price |
$31,802.50
|
| Rate for Payer: Cash Price |
$31,802.50
|
| Rate for Payer: Cigna Commercial |
$52,792.15
|
| Rate for Payer: First Health Commercial |
$60,424.75
|
| Rate for Payer: Humana Commercial |
$54,064.25
|
| Rate for Payer: Humana KY Medicaid |
$21,873.76
|
| Rate for Payer: Humana Medicare Advantage |
$65,476.58
|
| Rate for Payer: Kentucky WC Medicaid |
$22,096.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52,156.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,940.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78,571.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,312.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,972.40
|
| Rate for Payer: Ohio Health Group HMO |
$47,703.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,721.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,268.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,717.55
|
| Rate for Payer: PHCS Commercial |
$61,060.80
|
| Rate for Payer: United Healthcare All Payer |
$55,972.40
|
|
|
ZADITOR 0.025% DROPS 5ML
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 65401105
|
| Hospital Charge Code |
25001737
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna Commercial |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.09
|
| Rate for Payer: First Health Commercial |
$0.10
|
| Rate for Payer: Humana Commercial |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.10
|
| Rate for Payer: Ohio Health Group HMO |
$0.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
ZADITOR 0.025% DROPS 5ML
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 65401105
|
| Hospital Charge Code |
25001737
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna Commercial |
$0.08
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.09
|
| Rate for Payer: First Health Commercial |
$0.10
|
| Rate for Payer: Humana Commercial |
$0.09
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.10
|
| Rate for Payer: Ohio Health Group HMO |
$0.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
ZALTRAP 1MG[100MG/4ML VIAL]
|
Facility
|
IP
|
$8,720.00
|
|
|
Service Code
|
HCPCS J9400
|
| Hospital Charge Code |
25002695
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,133.60 |
| Max. Negotiated Rate |
$8,371.20 |
| Rate for Payer: Aetna Commercial |
$6,714.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,801.60
|
| Rate for Payer: Cash Price |
$4,360.00
|
| Rate for Payer: Cigna Commercial |
$7,237.60
|
| Rate for Payer: First Health Commercial |
$8,284.00
|
| Rate for Payer: Humana Commercial |
$7,412.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,150.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,435.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,673.60
|
| Rate for Payer: Ohio Health Group HMO |
$6,540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,133.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,703.20
|
| Rate for Payer: PHCS Commercial |
$8,371.20
|
| Rate for Payer: United Healthcare All Payer |
$7,673.60
|
|
|
ZALTRAP 1MG[100MG/4ML VIAL]
|
Facility
|
OP
|
$8,720.00
|
|
|
Service Code
|
HCPCS J9400
|
| Hospital Charge Code |
25002695
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$8,371.20 |
| Rate for Payer: Aetna Commercial |
$6,714.40
|
| Rate for Payer: Anthem Medicaid |
$2,998.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,801.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.83
|
| Rate for Payer: Cash Price |
$4,360.00
|
| Rate for Payer: Cash Price |
$4,360.00
|
| Rate for Payer: Cigna Commercial |
$7,237.60
|
| Rate for Payer: First Health Commercial |
$8,284.00
|
| Rate for Payer: Humana Commercial |
$7,412.00
|
| Rate for Payer: Humana KY Medicaid |
$2,998.81
|
| Rate for Payer: Humana Medicare Advantage |
$7.28
|
| Rate for Payer: Kentucky WC Medicaid |
$3,029.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,150.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,435.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,058.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,673.60
|
| Rate for Payer: Ohio Health Group HMO |
$6,540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,133.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,703.20
|
| Rate for Payer: PHCS Commercial |
$8,371.20
|
| Rate for Payer: United Healthcare All Payer |
$7,673.60
|
|
|
ZANAFLEX (TIZANIDINE) 2MG TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 55111017915
|
| Hospital Charge Code |
25001738
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
ZANAFLEX (TIZANIDINE) 2MG TAB
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 55111017915
|
| Hospital Charge Code |
25001738
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
ZANAFLEX (TIZANIDINE) 4 MG TAB
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 50268076015
|
| Hospital Charge Code |
25001739
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
ZANAFLEX (TIZANIDINE) 4 MG TAB
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 50268076015
|
| Hospital Charge Code |
25001739
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
|
|
ZAROXOLYN (METOLAZO 2.5MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 72888005201
|
| Hospital Charge Code |
25001744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
ZAROXOLYN (METOLAZO 2.5MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 72888005201
|
| Hospital Charge Code |
25001744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
ZAROXOLYN (METOLAZONE 5MG/1TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 72888005301
|
| Hospital Charge Code |
25001746
|
|
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
|
|
|
ZAROXOLYN (METOLAZONE 5MG/1TAB
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 72888005301
|
| Hospital Charge Code |
25001746
|
|
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
|
|
|
ZARXIO EAMCG (300MCG/0.5MLSYR)
|
Facility
|
IP
|
$1,495.26
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
25002723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.38 |
| Max. Negotiated Rate |
$1,435.45 |
| Rate for Payer: Aetna Commercial |
$1,151.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,166.30
|
| Rate for Payer: Cash Price |
$747.63
|
| Rate for Payer: Cigna Commercial |
$1,241.07
|
| Rate for Payer: First Health Commercial |
$1,420.50
|
| Rate for Payer: Humana Commercial |
$1,270.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,226.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,103.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$448.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,315.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,121.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$299.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$463.53
|
| Rate for Payer: PHCS Commercial |
$1,435.45
|
| Rate for Payer: United Healthcare All Payer |
$1,315.83
|
|
|
ZARXIO EAMCG (300MCG/0.5MLSYR)
|
Facility
|
OP
|
$1,495.26
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
25002723
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1,435.45 |
| Rate for Payer: Aetna Commercial |
$1,151.35
|
| Rate for Payer: Anthem Medicaid |
$514.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,166.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$747.63
|
| Rate for Payer: Cash Price |
$747.63
|
| Rate for Payer: Cigna Commercial |
$1,241.07
|
| Rate for Payer: First Health Commercial |
$1,420.50
|
| Rate for Payer: Humana Commercial |
$1,270.97
|
| Rate for Payer: Humana KY Medicaid |
$514.22
|
| Rate for Payer: Humana Medicare Advantage |
$0.32
|
| Rate for Payer: Kentucky WC Medicaid |
$519.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,226.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,103.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$524.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,315.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,121.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$299.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$463.53
|
| Rate for Payer: PHCS Commercial |
$1,435.45
|
| Rate for Payer: United Healthcare All Payer |
$1,315.83
|
|
