|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Professional
|
Both
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
77000049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$621.53 |
| Rate for Payer: Buckeye Medicare Advantage |
$621.53
|
| Rate for Payer: Cash Price |
$310.76
|
| Rate for Payer: Cash Price |
$310.76
|
| Rate for Payer: Healthspan PPO |
$183.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$373.75
|
| Rate for Payer: Multiplan PHCS |
$372.92
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$435.07
|
| Rate for Payer: UHCCP Medicaid |
$217.54
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Facility
|
OP
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
770T0049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.80 |
| Max. Negotiated Rate |
$596.67 |
| Rate for Payer: Aetna Commercial |
$478.58
|
| Rate for Payer: Anthem Medicaid |
$213.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$484.79
|
| Rate for Payer: Cash Price |
$310.76
|
| Rate for Payer: Cigna Commercial |
$515.87
|
| Rate for Payer: First Health Commercial |
$590.45
|
| Rate for Payer: Humana Commercial |
$528.30
|
| Rate for Payer: Humana KY Medicaid |
$213.74
|
| Rate for Payer: Kentucky WC Medicaid |
$215.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$509.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$458.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$218.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$546.95
|
| Rate for Payer: Ohio Health Group HMO |
$466.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.67
|
| Rate for Payer: PHCS Commercial |
$596.67
|
| Rate for Payer: United Healthcare All Payer |
$546.95
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Facility
|
IP
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
770T0049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.80 |
| Max. Negotiated Rate |
$596.67 |
| Rate for Payer: Aetna Commercial |
$478.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$484.79
|
| Rate for Payer: Cash Price |
$310.76
|
| Rate for Payer: Cigna Commercial |
$515.87
|
| Rate for Payer: First Health Commercial |
$590.45
|
| Rate for Payer: Humana Commercial |
$528.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$509.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$458.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$546.95
|
| Rate for Payer: Ohio Health Group HMO |
$466.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.67
|
| Rate for Payer: PHCS Commercial |
$596.67
|
| Rate for Payer: United Healthcare All Payer |
$546.95
|
|
|
ZOSTRIX(CAPSAICIN)0.025% 45GM
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 536252525
|
| Hospital Charge Code |
25001775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.09
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.10
|
| Rate for Payer: First Health Commercial |
$0.11
|
| Rate for Payer: Humana Commercial |
$0.10
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
ZOSTRIX(CAPSAICIN)0.025% 45GM
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 536252525
|
| Hospital Charge Code |
25001775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna Commercial |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.10
|
| Rate for Payer: First Health Commercial |
$0.11
|
| Rate for Payer: Humana Commercial |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.11
|
| Rate for Payer: Ohio Health Group HMO |
$0.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
|
ZO SULFUR MASK
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
22200167
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
ZOSYN 1.125gm (13.5gm package)
|
Facility
|
IP
|
$123.55
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25004167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.06 |
| Max. Negotiated Rate |
$118.61 |
| Rate for Payer: Aetna Commercial |
$95.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.37
|
| Rate for Payer: Cash Price |
$61.77
|
| Rate for Payer: Cigna Commercial |
$102.55
|
| Rate for Payer: First Health Commercial |
$117.37
|
| Rate for Payer: Humana Commercial |
$105.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.72
|
| Rate for Payer: Ohio Health Group HMO |
$92.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$118.61
|
| Rate for Payer: United Healthcare All Payer |
$108.72
|
|
|
ZOSYN 1.125gm (13.5gm package)
|
Facility
|
OP
|
$123.55
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25004167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.06 |
| Max. Negotiated Rate |
$118.61 |
| Rate for Payer: Aetna Commercial |
$95.13
|
| Rate for Payer: Anthem Medicaid |
$42.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.37
|
| Rate for Payer: Cash Price |
$61.77
|
| Rate for Payer: Cigna Commercial |
$102.55
|
| Rate for Payer: First Health Commercial |
$117.37
|
| Rate for Payer: Humana Commercial |
$105.02
|
| Rate for Payer: Humana KY Medicaid |
$42.49
|
| Rate for Payer: Kentucky WC Medicaid |
$42.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.72
|
| Rate for Payer: Ohio Health Group HMO |
$92.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$118.61
|
| Rate for Payer: United Healthcare All Payer |
$108.72
|
|
|
ZOSYN 1.125 GM (3.375 GM SOLN)
|
Facility
|
IP
|
$37.30
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25003756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$35.81 |
| Rate for Payer: Aetna Commercial |
$28.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.09
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Cigna Commercial |
$30.96
|
| Rate for Payer: First Health Commercial |
$35.44
|
| Rate for Payer: Humana Commercial |
$31.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.82
|
| Rate for Payer: Ohio Health Group HMO |
$27.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.56
|
| Rate for Payer: PHCS Commercial |
$35.81
|
| Rate for Payer: United Healthcare All Payer |
$32.82
|
|
|
ZOSYN 1.125 GM (3.375 GM SOLN)
|
Facility
|
OP
|
$37.30
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25003756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$35.81 |
| Rate for Payer: Aetna Commercial |
$28.72
|
| Rate for Payer: Anthem Medicaid |
$12.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.09
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Cigna Commercial |
$30.96
|
| Rate for Payer: First Health Commercial |
$35.44
|
| Rate for Payer: Humana Commercial |
$31.70
|
| Rate for Payer: Humana KY Medicaid |
$12.83
|
| Rate for Payer: Kentucky WC Medicaid |
$12.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.82
|
| Rate for Payer: Ohio Health Group HMO |
$27.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.56
|
| Rate for Payer: PHCS Commercial |
$35.81
|
| Rate for Payer: United Healthcare All Payer |
$32.82
|
|
|
ZOSYN 1.125 GM (4.5GM SDV)
|
Facility
|
OP
|
$117.58
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25002309
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$112.88 |
| Rate for Payer: Kentucky WC Medicaid |
$40.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.47
|
| Rate for Payer: Ohio Health Group HMO |
$88.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.45
|
| Rate for Payer: PHCS Commercial |
$112.88
|
| Rate for Payer: United Healthcare All Payer |
$103.47
|
| Rate for Payer: Aetna Commercial |
$90.54
|
| Rate for Payer: Anthem Medicaid |
$40.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.71
|
| Rate for Payer: Cash Price |
$58.79
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: First Health Commercial |
$111.70
|
| Rate for Payer: Humana Commercial |
$99.94
|
| Rate for Payer: Humana KY Medicaid |
$40.44
|
|
|
ZOSYN 1.125 GM (4.5GM SDV)
|
Facility
|
IP
|
$117.58
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25002309
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$112.88 |
| Rate for Payer: Aetna Commercial |
$90.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.71
|
| Rate for Payer: Cash Price |
$58.79
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: First Health Commercial |
$111.70
|
| Rate for Payer: Humana Commercial |
$99.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.47
|
| Rate for Payer: Ohio Health Group HMO |
$88.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.45
|
| Rate for Payer: PHCS Commercial |
$112.88
|
| Rate for Payer: United Healthcare All Payer |
$103.47
|
|
|
ZOSYN 1.125 GM (4.5 GM SOLN)
|
Facility
|
IP
|
$181.38
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25002313
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.58 |
| Max. Negotiated Rate |
$174.12 |
| Rate for Payer: Aetna Commercial |
$139.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.48
|
| Rate for Payer: Cash Price |
$90.69
|
| Rate for Payer: Cigna Commercial |
$150.55
|
| Rate for Payer: First Health Commercial |
$172.31
|
| Rate for Payer: Humana Commercial |
$154.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.61
|
| Rate for Payer: Ohio Health Group HMO |
$136.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.23
|
| Rate for Payer: PHCS Commercial |
$174.12
|
| Rate for Payer: United Healthcare All Payer |
$159.61
|
|
|
ZOSYN 1.125 GM (4.5 GM SOLN)
|
Facility
|
OP
|
$181.38
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25002313
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.58 |
| Max. Negotiated Rate |
$174.12 |
| Rate for Payer: Aetna Commercial |
$139.66
|
| Rate for Payer: Anthem Medicaid |
$62.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.48
|
| Rate for Payer: Cash Price |
$90.69
|
| Rate for Payer: Cigna Commercial |
$150.55
|
| Rate for Payer: First Health Commercial |
$172.31
|
| Rate for Payer: Humana Commercial |
$154.17
|
| Rate for Payer: Humana KY Medicaid |
$62.38
|
| Rate for Payer: Kentucky WC Medicaid |
$63.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.61
|
| Rate for Payer: Ohio Health Group HMO |
$136.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.23
|
| Rate for Payer: PHCS Commercial |
$174.12
|
| Rate for Payer: United Healthcare All Payer |
$159.61
|
|
|
ZOSYN 2.25 GM/10 ML
|
Facility
|
IP
|
$44.15
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25004421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$42.38 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$38.85
|
| Rate for Payer: Ohio Health Group HMO |
$33.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.69
|
| Rate for Payer: PHCS Commercial |
$42.38
|
| Rate for Payer: United Healthcare All Payer |
$38.85
|
| Rate for Payer: Aetna Commercial |
$34.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34.44
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Cigna Commercial |
$36.64
|
| Rate for Payer: First Health Commercial |
$41.94
|
| Rate for Payer: Humana Commercial |
$37.53
|
|
|
ZOSYN 2.25 GM/10 ML
|
Facility
|
OP
|
$44.15
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25004421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$42.38 |
| Rate for Payer: Aetna Commercial |
$34.00
|
| Rate for Payer: Anthem Medicaid |
$15.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34.44
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Cigna Commercial |
$36.64
|
| Rate for Payer: First Health Commercial |
$41.94
|
| Rate for Payer: Humana Commercial |
$37.53
|
| Rate for Payer: Humana KY Medicaid |
$15.18
|
| Rate for Payer: Kentucky WC Medicaid |
$15.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$38.85
|
| Rate for Payer: Ohio Health Group HMO |
$33.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.69
|
| Rate for Payer: PHCS Commercial |
$42.38
|
| Rate for Payer: United Healthcare All Payer |
$38.85
|
|
|
ZOVIRAX (ACYCLOVIR) 200MG/1CAP
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 904578961
|
| Hospital Charge Code |
25001776
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
ZOVIRAX (ACYCLOVIR) 200MG/1CAP
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 904578961
|
| Hospital Charge Code |
25001776
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
ZOVIRAX(ACYCLOVIR)200MG 5ML
|
Facility
|
IP
|
$11.76
|
|
|
Service Code
|
NDC 472008216
|
| Hospital Charge Code |
25003642
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.29 |
| Rate for Payer: Aetna Commercial |
$9.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.17
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Cigna Commercial |
$9.76
|
| Rate for Payer: First Health Commercial |
$11.17
|
| Rate for Payer: Humana Commercial |
$10.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.35
|
| Rate for Payer: Ohio Health Group HMO |
$8.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.65
|
| Rate for Payer: PHCS Commercial |
$11.29
|
| Rate for Payer: United Healthcare All Payer |
$10.35
|
|
|
ZOVIRAX(ACYCLOVIR)200MG 5ML
|
Facility
|
OP
|
$11.76
|
|
|
Service Code
|
NDC 472008216
|
| Hospital Charge Code |
25003642
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.29 |
| Rate for Payer: Aetna Commercial |
$9.06
|
| Rate for Payer: Anthem Medicaid |
$4.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.17
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Cigna Commercial |
$9.76
|
| Rate for Payer: First Health Commercial |
$11.17
|
| Rate for Payer: Humana Commercial |
$10.00
|
| Rate for Payer: Humana KY Medicaid |
$4.04
|
| Rate for Payer: Kentucky WC Medicaid |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.35
|
| Rate for Payer: Ohio Health Group HMO |
$8.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.65
|
| Rate for Payer: PHCS Commercial |
$11.29
|
| Rate for Payer: United Healthcare All Payer |
$10.35
|
|
|
ZOVIRAX(ACYCLOVIR) 5% OIN 15GM
|
Facility
|
IP
|
$11.73
|
|
|
Service Code
|
NDC 51672136001
|
| Hospital Charge Code |
25001779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.15
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.14
|
| Rate for Payer: Humana Commercial |
$9.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.32
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Payer |
$10.32
|
|
|
ZOVIRAX(ACYCLOVIR) 5% OIN 15GM
|
Facility
|
OP
|
$11.73
|
|
|
Service Code
|
NDC 51672136001
|
| Hospital Charge Code |
25001779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Anthem Medicaid |
$4.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.15
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.14
|
| Rate for Payer: Humana Commercial |
$9.97
|
| Rate for Payer: Humana KY Medicaid |
$4.03
|
| Rate for Payer: Kentucky WC Medicaid |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.32
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Payer |
$10.32
|
|
|
ZOVIRAX (ACYCLOVIR) 800MG/1TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 69452029120
|
| Hospital Charge Code |
25001777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
ZOVIRAX (ACYCLOVIR) 800MG/1TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 69452029120
|
| Hospital Charge Code |
25001777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
ZR 12/14 TAPER FEM HD 22MM +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
|
|
