|
ZIAC (BISOPROLOL) 10 10MG/1TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 29300018901
|
| Hospital Charge Code |
25001751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| 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 |
$1.35 |
| 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 |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| 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 |
$1.35 |
| 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 |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
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 |
$1.39 |
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
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 |
$1.39 |
| 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 |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
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 |
$27.99 |
| 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 |
$27.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,687.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.79
|
| 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 |
$27.99
|
| 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 |
$33.59
|
| 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 |
$17,115.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,612.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,761.96
|
| Rate for Payer: PHCS Commercial |
$20,538.37
|
| Rate for Payer: United Healthcare All Payer |
$18,826.84
|
|
|
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 |
$6,418.24 |
| 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 |
$17,115.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,612.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,761.96
|
| Rate for Payer: PHCS Commercial |
$20,538.37
|
| Rate for Payer: United Healthcare All Payer |
$18,826.84
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
OP
|
$114.79
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
636T0182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$88.39
|
| Rate for Payer: Anthem Medicaid |
$39.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.58
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cigna Commercial |
$95.28
|
| Rate for Payer: First Health Commercial |
$109.05
|
| Rate for Payer: Humana Commercial |
$97.57
|
| Rate for Payer: Humana KY Medicaid |
$39.48
|
| Rate for Payer: Humana Medicare Advantage |
$18.21
|
| Rate for Payer: Kentucky WC Medicaid |
$39.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.02
|
| Rate for Payer: Ohio Health Group HMO |
$86.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.21
|
| Rate for Payer: PHCS Commercial |
$110.20
|
| Rate for Payer: United Healthcare All Payer |
$101.02
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
IP
|
$3,746.82
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
25004333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,124.05 |
| Max. Negotiated Rate |
$3,596.95 |
| Rate for Payer: Aetna Commercial |
$2,885.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,922.52
|
| Rate for Payer: Cash Price |
$1,873.41
|
| Rate for Payer: Cigna Commercial |
$3,109.86
|
| Rate for Payer: First Health Commercial |
$3,559.48
|
| Rate for Payer: Humana Commercial |
$3,184.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,072.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,765.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,124.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,297.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,810.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,997.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,259.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,585.31
|
| Rate for Payer: PHCS Commercial |
$3,596.95
|
| Rate for Payer: United Healthcare All Payer |
$3,297.20
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
OP
|
$114.79
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
63600182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$88.39
|
| Rate for Payer: Anthem Medicaid |
$39.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.58
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cigna Commercial |
$95.28
|
| Rate for Payer: First Health Commercial |
$109.05
|
| Rate for Payer: Humana Commercial |
$97.57
|
| Rate for Payer: Humana KY Medicaid |
$39.48
|
| Rate for Payer: Humana Medicare Advantage |
$18.21
|
| Rate for Payer: Kentucky WC Medicaid |
$39.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.02
|
| Rate for Payer: Ohio Health Group HMO |
$86.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.21
|
| Rate for Payer: PHCS Commercial |
$110.20
|
| Rate for Payer: United Healthcare All Payer |
$101.02
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
IP
|
$114.79
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
63600182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$88.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.54
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cigna Commercial |
$95.28
|
| Rate for Payer: First Health Commercial |
$109.05
|
| Rate for Payer: Humana Commercial |
$97.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.02
|
| Rate for Payer: Ohio Health Group HMO |
$86.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.21
|
| Rate for Payer: PHCS Commercial |
$110.20
|
| Rate for Payer: United Healthcare All Payer |
$101.02
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
IP
|
$114.79
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
636T0182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$88.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.54
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cigna Commercial |
$95.28
|
| Rate for Payer: First Health Commercial |
$109.05
|
| Rate for Payer: Humana Commercial |
$97.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.02
|
| Rate for Payer: Ohio Health Group HMO |
$86.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.21
|
| Rate for Payer: PHCS Commercial |
$110.20
|
| Rate for Payer: United Healthcare All Payer |
$101.02
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Professional
|
Both
|
$114.79
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
63600182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Ambetter Exchange |
$18.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$21.85
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.21
|
| Rate for Payer: Multiplan PHCS |
$68.87
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.67
|
| Rate for Payer: UHCCP Medicaid |
$40.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.21
|
|
|
ZILRETTA 1mg (32mg SDV)
|
Facility
|
OP
|
$3,746.82
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
25004333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$3,596.95 |
| Rate for Payer: Aetna Commercial |
$2,885.05
|
| Rate for Payer: Anthem Medicaid |
$1,288.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,922.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.58
|
| Rate for Payer: Cash Price |
$1,873.41
|
| Rate for Payer: Cash Price |
$1,873.41
|
| Rate for Payer: Cigna Commercial |
$3,109.86
|
| Rate for Payer: First Health Commercial |
$3,559.48
|
| Rate for Payer: Humana Commercial |
$3,184.80
|
| Rate for Payer: Humana KY Medicaid |
$1,288.53
|
| Rate for Payer: Humana Medicare Advantage |
$18.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,301.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,072.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,765.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,314.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,297.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,810.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,997.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,259.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,585.31
|
| Rate for Payer: PHCS Commercial |
$3,596.95
|
| Rate for Payer: United Healthcare All Payer |
$3,297.20
|
|
|
ZILVER PTX 35*125*5*140
|
Facility
|
IP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
ZILVER PTX 35*125*5*140
|
Facility
|
OP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem Medicaid |
$4,226.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Humana KY Medicaid |
$4,226.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,269.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,311.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
ZIMMER AS HUM STEM FX 10-130
|
Facility
|
IP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 10-130
|
Facility
|
OP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem Medicaid |
$8,072.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Humana KY Medicaid |
$8,072.19
|
| Rate for Payer: Kentucky WC Medicaid |
$8,154.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,234.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 11-130
|
Facility
|
IP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 11-130
|
Facility
|
OP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem Medicaid |
$8,072.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Humana KY Medicaid |
$8,072.19
|
| Rate for Payer: Kentucky WC Medicaid |
$8,154.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,234.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 12-130
|
Facility
|
OP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem Medicaid |
$8,072.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Humana KY Medicaid |
$8,072.19
|
| Rate for Payer: Kentucky WC Medicaid |
$8,154.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,234.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 12-130
|
Facility
|
IP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 13-130
|
Facility
|
IP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 13-130
|
Facility
|
OP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem Medicaid |
$8,072.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Humana KY Medicaid |
$8,072.19
|
| Rate for Payer: Kentucky WC Medicaid |
$8,154.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,234.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
|
ZIMMER AS HUM STEM FX 14-130
|
Facility
|
OP
|
$23,472.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,041.75 |
| Max. Negotiated Rate |
$22,533.60 |
| Rate for Payer: Aetna Commercial |
$18,073.83
|
| Rate for Payer: Anthem Medicaid |
$8,072.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,308.55
|
| Rate for Payer: Cash Price |
$11,736.25
|
| Rate for Payer: Cigna Commercial |
$19,482.17
|
| Rate for Payer: First Health Commercial |
$22,298.88
|
| Rate for Payer: Humana Commercial |
$19,951.62
|
| Rate for Payer: Humana KY Medicaid |
$8,072.19
|
| Rate for Payer: Kentucky WC Medicaid |
$8,154.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,247.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,322.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,041.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,234.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,655.80
|
| Rate for Payer: Ohio Health Group HMO |
$17,604.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,778.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,421.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,196.02
|
| Rate for Payer: PHCS Commercial |
$22,533.60
|
| Rate for Payer: United Healthcare All Payer |
$20,655.80
|
|
