|
ZR 12/14 TAPER FEM HD 22MM +8
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +0
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +0
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +4
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +4
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +8
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +8
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +0
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +0
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +4
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +4
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +8
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +8
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
ZYLOPRIM (ALLOPURIN 100MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 60687067701
|
| Hospital Charge Code |
25001782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| 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 |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| 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 |
$1.38 |
| 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 |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
ZYPREXA 10MG TABLET
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 43598016630
|
| Hospital Charge Code |
25003645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
ZYPREXA 10MG TABLET
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 43598016630
|
| Hospital Charge Code |
25003645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
ZYPREXA (OLANZAPINE) 5 MG TAB
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 60505311100
|
| Hospital Charge Code |
25001784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| 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 |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.33 |
| 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 |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| 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 |
$1.52 |
| 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 |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| 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 |
$1.52 |
| 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 |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
ZYPREX (OLANZAPINE) 2.5MG TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 60505311000
|
| Hospital Charge Code |
25001783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
ZYPREX (OLANZAPINE) 2.5MG TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 60505311000
|
| Hospital Charge Code |
25001783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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 |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
ZYRTEC (CETIRIZINE) 10MG/1TAB
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 904671761
|
| Hospital Charge Code |
25001786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
ZYRTEC (CETIRIZINE) 10MG/1TAB
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 904671761
|
| Hospital Charge Code |
25001786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
