|
ZENITH AAA ILIAC LEG EXT 24*55
|
Facility
|
OP
|
$9,384.60
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,220.00 |
| Max. Negotiated Rate |
$9,009.22 |
| Rate for Payer: Aetna Commercial |
$7,226.14
|
| Rate for Payer: Anthem Medicaid |
$3,227.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,319.99
|
| Rate for Payer: Cash Price |
$4,692.30
|
| Rate for Payer: Cigna Commercial |
$7,789.22
|
| Rate for Payer: First Health Commercial |
$8,915.37
|
| Rate for Payer: Humana Commercial |
$7,976.91
|
| Rate for Payer: Humana KY Medicaid |
$3,227.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,260.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,695.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,925.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,815.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,292.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,258.45
|
| Rate for Payer: Ohio Health Group HMO |
$7,038.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,876.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,909.23
|
| Rate for Payer: PHCS Commercial |
$9,009.22
|
| Rate for Payer: United Healthcare All Payer |
$8,258.45
|
|
|
ZENITH AAA ILIAC PLG ZIP-14-30
|
Facility
|
IP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLG ZIP-14-30
|
Facility
|
OP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem Medicaid |
$3,262.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Humana KY Medicaid |
$3,262.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,295.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,327.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLG ZIP-16-30
|
Facility
|
IP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLG ZIP-16-30
|
Facility
|
OP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem Medicaid |
$3,262.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Humana KY Medicaid |
$3,262.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,295.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,327.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLG ZIP-20-30
|
Facility
|
IP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLG ZIP-20-30
|
Facility
|
OP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem Medicaid |
$3,262.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Humana KY Medicaid |
$3,262.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,295.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,327.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLUGZIP-24-30
|
Facility
|
OP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem Medicaid |
$3,262.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Humana KY Medicaid |
$3,262.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,295.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,327.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZENITH AAA ILIAC PLUGZIP-24-30
|
Facility
|
IP
|
$9,486.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.28 |
| Max. Negotiated Rate |
$9,107.33 |
| Rate for Payer: Aetna Commercial |
$7,304.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,399.70
|
| Rate for Payer: Cash Price |
$4,743.40
|
| Rate for Payer: Cigna Commercial |
$7,874.04
|
| Rate for Payer: First Health Commercial |
$9,012.46
|
| Rate for Payer: Humana Commercial |
$8,063.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,779.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,001.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,846.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,348.38
|
| Rate for Payer: Ohio Health Group HMO |
$7,115.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,897.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,233.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,940.91
|
| Rate for Payer: PHCS Commercial |
$9,107.33
|
| Rate for Payer: United Healthcare All Payer |
$8,348.38
|
|
|
ZERBAXA 75mg (1.5gm SDV)
|
Facility
|
IP
|
$864.64
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
25003946
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$830.05 |
| Rate for Payer: Aetna Commercial |
$665.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$674.42
|
| Rate for Payer: Cash Price |
$432.32
|
| Rate for Payer: Cigna Commercial |
$717.65
|
| Rate for Payer: First Health Commercial |
$821.41
|
| Rate for Payer: Humana Commercial |
$734.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$709.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$638.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$259.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$760.88
|
| Rate for Payer: Ohio Health Group HMO |
$648.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$268.04
|
| Rate for Payer: PHCS Commercial |
$830.05
|
| Rate for Payer: United Healthcare All Payer |
$760.88
|
|
|
ZERBAXA 75mg (1.5gm SDV)
|
Facility
|
OP
|
$864.64
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
25003946
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$830.05 |
| Rate for Payer: Aetna Commercial |
$665.77
|
| Rate for Payer: Anthem Medicaid |
$297.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$674.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.95
|
| Rate for Payer: Cash Price |
$432.32
|
| Rate for Payer: Cash Price |
$432.32
|
| Rate for Payer: Cigna Commercial |
$717.65
|
| Rate for Payer: First Health Commercial |
$821.41
|
| Rate for Payer: Humana Commercial |
$734.94
|
| Rate for Payer: Humana KY Medicaid |
$297.35
|
| Rate for Payer: Humana Medicare Advantage |
$7.37
|
| Rate for Payer: Kentucky WC Medicaid |
$300.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$709.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$638.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$303.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$760.88
|
| Rate for Payer: Ohio Health Group HMO |
$648.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$268.04
|
| Rate for Payer: PHCS Commercial |
$830.05
|
| Rate for Payer: United Healthcare All Payer |
$760.88
|
|
|
ZETIA (EZETIMIBIE) 10 MG TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 59651005290
|
| Hospital Charge Code |
25001750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
ZETIA (EZETIMIBIE) 10 MG TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 59651005290
|
| Hospital Charge Code |
25001750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
ZIAC (BISOPROLOL) 10 10MG/1TAB
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 29300018901
|
| Hospital Charge Code |
25001751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
ZIAC (BISOPROLOL) 10 10MG/1TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 29300018901
|
| Hospital Charge Code |
25001751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
ZIAC (BISOPROLOL) 2 2.5MG/1TAB
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
NDC 29300018705
|
| Hospital Charge Code |
25001752
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
ZIAC (BISOPROLOL) 2 2.5MG/1TAB
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
NDC 29300018705
|
| Hospital Charge Code |
25001752
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
ZIAC (BISOPROLOL) 5 M 5MG/TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 29300018801
|
| Hospital Charge Code |
25001753
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
ZIAC (BISOPROLOL) 5 M 5MG/TAB
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 29300018801
|
| Hospital Charge Code |
25001753
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
ZIEXTENZO 0.5mg (6mg PFS)
|
Facility
|
IP
|
$21,394.14
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
25004107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,781.24 |
| Max. Negotiated Rate |
$20,538.37 |
| Rate for Payer: Aetna Commercial |
$16,473.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,687.43
|
| Rate for Payer: Cash Price |
$10,697.07
|
| Rate for Payer: Cigna Commercial |
$17,757.14
|
| Rate for Payer: First Health Commercial |
$20,324.43
|
| Rate for Payer: Humana Commercial |
$18,185.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,543.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,788.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,418.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,826.84
|
| Rate for Payer: Ohio Health Group HMO |
$16,045.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,278.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,781.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,632.18
|
| Rate for Payer: PHCS Commercial |
$20,538.37
|
| Rate for Payer: United Healthcare All Payer |
$18,826.84
|
|
|
ZIEXTENZO 0.5mg (6mg PFS)
|
Facility
|
OP
|
$21,394.14
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
25004107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$346.76 |
| Max. Negotiated Rate |
$20,538.37 |
| Rate for Payer: Aetna Commercial |
$16,473.49
|
| Rate for Payer: Anthem Medicaid |
$7,357.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$346.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,687.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$485.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$468.12
|
| Rate for Payer: Cash Price |
$10,697.07
|
| Rate for Payer: Cash Price |
$10,697.07
|
| Rate for Payer: Cigna Commercial |
$17,757.14
|
| Rate for Payer: First Health Commercial |
$20,324.43
|
| Rate for Payer: Humana Commercial |
$18,185.02
|
| Rate for Payer: Humana KY Medicaid |
$7,357.44
|
| Rate for Payer: Humana Medicare Advantage |
$346.76
|
| Rate for Payer: Kentucky WC Medicaid |
$7,432.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,543.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,788.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$416.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,505.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,826.84
|
| Rate for Payer: Ohio Health Group HMO |
$16,045.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,278.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,781.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,632.18
|
| Rate for Payer: PHCS Commercial |
$20,538.37
|
| Rate for Payer: United Healthcare All Payer |
$18,826.84
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
IP
|
$102.16
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
636T0182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$98.07 |
| Rate for Payer: Aetna Commercial |
$78.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.68
|
| Rate for Payer: Cash Price |
$51.08
|
| Rate for Payer: Cigna Commercial |
$84.79
|
| Rate for Payer: First Health Commercial |
$97.05
|
| Rate for Payer: Humana Commercial |
$86.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.90
|
| Rate for Payer: Ohio Health Group HMO |
$76.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.67
|
| Rate for Payer: PHCS Commercial |
$98.07
|
| Rate for Payer: United Healthcare All Payer |
$89.90
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
OP
|
$102.16
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
63600182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$98.07 |
| Rate for Payer: Aetna Commercial |
$78.66
|
| Rate for Payer: Anthem Medicaid |
$35.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.68
|
| Rate for Payer: Cash Price |
$51.08
|
| Rate for Payer: Cash Price |
$51.08
|
| Rate for Payer: Cigna Commercial |
$84.79
|
| Rate for Payer: First Health Commercial |
$97.05
|
| Rate for Payer: Humana Commercial |
$86.84
|
| Rate for Payer: Humana KY Medicaid |
$35.13
|
| Rate for Payer: Humana Medicare Advantage |
$17.54
|
| Rate for Payer: Kentucky WC Medicaid |
$35.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.90
|
| Rate for Payer: Ohio Health Group HMO |
$76.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.67
|
| Rate for Payer: PHCS Commercial |
$98.07
|
| Rate for Payer: United Healthcare All Payer |
$89.90
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
OP
|
$3,601.31
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
25004333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$3,457.26 |
| Rate for Payer: Aetna Commercial |
$2,773.01
|
| Rate for Payer: Anthem Medicaid |
$1,238.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,809.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.68
|
| Rate for Payer: Cash Price |
$1,800.65
|
| Rate for Payer: Cash Price |
$1,800.65
|
| Rate for Payer: Cigna Commercial |
$2,989.09
|
| Rate for Payer: First Health Commercial |
$3,421.24
|
| Rate for Payer: Humana Commercial |
$3,061.11
|
| Rate for Payer: Humana KY Medicaid |
$1,238.49
|
| Rate for Payer: Humana Medicare Advantage |
$17.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,251.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,953.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,657.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,263.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,169.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.41
|
| Rate for Payer: PHCS Commercial |
$3,457.26
|
| Rate for Payer: United Healthcare All Payer |
$3,169.15
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
IP
|
$102.16
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
63600182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$98.07 |
| Rate for Payer: Aetna Commercial |
$78.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.68
|
| Rate for Payer: Cash Price |
$51.08
|
| Rate for Payer: Cigna Commercial |
$84.79
|
| Rate for Payer: First Health Commercial |
$97.05
|
| Rate for Payer: Humana Commercial |
$86.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.90
|
| Rate for Payer: Ohio Health Group HMO |
$76.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.67
|
| Rate for Payer: PHCS Commercial |
$98.07
|
| Rate for Payer: United Healthcare All Payer |
$89.90
|
|
