|
ZR 12/14 TAPER FEM HD 22MM +4
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 22MM +8
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 22MM +8
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +0
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +0
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +4
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +4
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +8
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +8
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +0
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +0
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +4
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +4
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +8
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +8
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZYLOPRIM (ALLOPURIN 100MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 60687067701
|
| Hospital Charge Code |
25001782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| 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 |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| 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 |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
ZYLOPRIM (ALLOPURIN 100MG/1TAB
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 60687067701
|
| Hospital Charge Code |
25001782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| 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 |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| 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 |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
ZYPREXA 10MG TABLET
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
NDC 43598016630
|
| Hospital Charge Code |
25003645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
ZYPREXA 10MG TABLET
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
NDC 43598016630
|
| Hospital Charge Code |
25003645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
ZYPREXA (OLANZAPINE) 5 MG TAB
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 60505311100
|
| Hospital Charge Code |
25001784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| 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 |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
ZYPREXA (OLANZAPINE) 5 MG TAB
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
NDC 60505311100
|
| Hospital Charge Code |
25001784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| 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 |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
ZYPREXA ZYDIS 5MG TAB
|
Facility
|
OP
|
$5.06
|
|
|
Service Code
|
NDC 64380017202
|
| Hospital Charge Code |
25001785
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cigna Commercial |
$4.20
|
| Rate for Payer: First Health Commercial |
$4.81
|
| Rate for Payer: Humana Commercial |
$4.30
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.45
|
| Rate for Payer: Ohio Health Group HMO |
$3.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
ZYPREXA ZYDIS 5MG TAB
|
Facility
|
IP
|
$5.06
|
|
|
Service Code
|
NDC 64380017202
|
| Hospital Charge Code |
25001785
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cigna Commercial |
$4.20
|
| Rate for Payer: First Health Commercial |
$4.81
|
| Rate for Payer: Humana Commercial |
$4.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.45
|
| Rate for Payer: Ohio Health Group HMO |
$3.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
ZYPREX (OLANZAPINE) 2.5MG TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60505311000
|
| Hospital Charge Code |
25001783
|
|
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
|
|
|
ZYPREX (OLANZAPINE) 2.5MG TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60505311000
|
| Hospital Charge Code |
25001783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| 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
|
| Rate for Payer: Aetna Commercial |
$3.39
|
|
