|
ZOFRAN 1MG (4MG/2ML VL)
|
Facility
|
OP
|
$15.87
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
636T0046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Anthem Medicaid |
$5.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.38
|
| Rate for Payer: Cash Price |
$7.93
|
| Rate for Payer: Cigna Commercial |
$13.17
|
| Rate for Payer: First Health Commercial |
$15.08
|
| Rate for Payer: Humana Commercial |
$13.49
|
| Rate for Payer: Humana KY Medicaid |
$5.46
|
| Rate for Payer: Kentucky WC Medicaid |
$5.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.97
|
| Rate for Payer: Ohio Health Group HMO |
$11.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.95
|
| Rate for Payer: PHCS Commercial |
$15.24
|
| Rate for Payer: United Healthcare All Payer |
$13.97
|
|
|
ZOFRAN 1MG (4MG/2ML VL)
|
Professional
|
Both
|
$15.87
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
63600046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$9.52 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Ambetter Exchange |
$0.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$7.93
|
| Rate for Payer: Cash Price |
$7.93
|
| Rate for Payer: Healthspan PPO |
$0.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$0.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.09
|
| Rate for Payer: Multiplan PHCS |
$9.52
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$0.12
|
| Rate for Payer: UHCCP Medicaid |
$5.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.09
|
|
|
ZOFRAN 1MG (4MG/2ML VL)
|
Facility
|
IP
|
$15.87
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
636T0046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.38
|
| Rate for Payer: Cash Price |
$7.93
|
| Rate for Payer: Cigna Commercial |
$13.17
|
| Rate for Payer: First Health Commercial |
$15.08
|
| Rate for Payer: Humana Commercial |
$13.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.97
|
| Rate for Payer: Ohio Health Group HMO |
$11.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.95
|
| Rate for Payer: PHCS Commercial |
$15.24
|
| Rate for Payer: United Healthcare All Payer |
$13.97
|
|
|
ZOFRAN EQ 2MG/2.5MLORALSOL2.5
|
Facility
|
OP
|
$12.20
|
|
|
Service Code
|
NDC 54006447
|
| Hospital Charge Code |
25001765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$11.71 |
| Rate for Payer: Aetna Commercial |
$9.39
|
| Rate for Payer: Anthem Medicaid |
$4.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.52
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna Commercial |
$10.13
|
| Rate for Payer: First Health Commercial |
$11.59
|
| Rate for Payer: Humana Commercial |
$10.37
|
| Rate for Payer: Humana KY Medicaid |
$4.20
|
| Rate for Payer: Kentucky WC Medicaid |
$4.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.74
|
| Rate for Payer: Ohio Health Group HMO |
$9.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.42
|
| Rate for Payer: PHCS Commercial |
$11.71
|
| Rate for Payer: United Healthcare All Payer |
$10.74
|
|
|
ZOFRAN EQ 2MG/2.5MLORALSOL2.5
|
Facility
|
IP
|
$12.20
|
|
|
Service Code
|
NDC 54006447
|
| Hospital Charge Code |
25001765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$11.71 |
| Rate for Payer: Aetna Commercial |
$9.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.52
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna Commercial |
$10.13
|
| Rate for Payer: First Health Commercial |
$11.59
|
| Rate for Payer: Humana Commercial |
$10.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.74
|
| Rate for Payer: Ohio Health Group HMO |
$9.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.42
|
| Rate for Payer: PHCS Commercial |
$11.71
|
| Rate for Payer: United Healthcare All Payer |
$10.74
|
|
|
ZOFRAN ODT 4 MG TABLET
|
Facility
|
IP
|
$4.89
|
|
|
Service Code
|
NDC 68001024617
|
| Hospital Charge Code |
25001766
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.06
|
| Rate for Payer: First Health Commercial |
$4.65
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.30
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.69
|
| Rate for Payer: United Healthcare All Payer |
$4.30
|
|
|
ZOFRAN ODT 4 MG TABLET
|
Facility
|
OP
|
$4.89
|
|
|
Service Code
|
NDC 68001024617
|
| Hospital Charge Code |
25001766
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.06
|
| Rate for Payer: First Health Commercial |
$4.65
|
| Rate for Payer: Humana Commercial |
$4.16
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.30
|
| Rate for Payer: Ohio Health Group HMO |
$3.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.37
|
| Rate for Payer: PHCS Commercial |
$4.69
|
| Rate for Payer: United Healthcare All Payer |
$4.30
|
|
|
ZOFRAN ODT 8 MG TAB
|
Facility
|
IP
|
$9.13
|
|
|
Service Code
|
NDC 68001024717
|
| Hospital Charge Code |
25003639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Cash Price |
$4.57
|
| Rate for Payer: Cigna Commercial |
$7.58
|
| Rate for Payer: First Health Commercial |
$8.67
|
| Rate for Payer: Humana Commercial |
$7.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.30
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
ZOFRAN ODT 8 MG TAB
|
Facility
|
OP
|
$9.13
|
|
|
Service Code
|
NDC 68001024717
|
| Hospital Charge Code |
25003639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$8.76 |
| Rate for Payer: Aetna Commercial |
$7.03
|
| Rate for Payer: Anthem Medicaid |
$3.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.12
|
| Rate for Payer: Cash Price |
$4.57
|
| Rate for Payer: Cigna Commercial |
$7.58
|
| Rate for Payer: First Health Commercial |
$8.67
|
| Rate for Payer: Humana Commercial |
$7.76
|
| Rate for Payer: Humana KY Medicaid |
$3.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.03
|
| Rate for Payer: Ohio Health Group HMO |
$6.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.30
|
| Rate for Payer: PHCS Commercial |
$8.76
|
| Rate for Payer: United Healthcare All Payer |
$8.03
|
|
|
ZOFRAN (ONDANSETRON) 4MG/1TAB
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 68084022001
|
| Hospital Charge Code |
25001764
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
ZOFRAN (ONDANSETRON) 4MG/1TAB
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 68084022001
|
| Hospital Charge Code |
25001764
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
ZOFRAN (ONDANSETRON H 8MG/1TAB
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 57237007630
|
| Hospital Charge Code |
25001763
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
ZOFRAN (ONDANSETRON H 8MG/1TAB
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 57237007630
|
| Hospital Charge Code |
25001763
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
ZO HYDRAFIRM EYE BRIGHTNNG RPR
|
Professional
|
Both
|
$140.00
|
|
| Hospital Charge Code |
22200203
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Multiplan PHCS |
$84.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$98.00
|
| Rate for Payer: UHCCP Medicaid |
$49.00
|
|
|
ZO HYDRATING CREME
|
Facility
|
IP
|
$94.00
|
|
| Hospital Charge Code |
22200168
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$90.24 |
| Rate for Payer: Aetna Commercial |
$72.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.32
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cigna Commercial |
$78.02
|
| Rate for Payer: First Health Commercial |
$89.30
|
| Rate for Payer: Humana Commercial |
$79.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.72
|
| Rate for Payer: Ohio Health Group HMO |
$70.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.86
|
| Rate for Payer: PHCS Commercial |
$90.24
|
| Rate for Payer: United Healthcare All Payer |
$82.72
|
|
|
ZO HYDRATING CREME
|
Facility
|
OP
|
$94.00
|
|
| Hospital Charge Code |
22200168
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$90.24 |
| Rate for Payer: Aetna Commercial |
$72.38
|
| Rate for Payer: Anthem Medicaid |
$32.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.32
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cigna Commercial |
$78.02
|
| Rate for Payer: First Health Commercial |
$89.30
|
| Rate for Payer: Humana Commercial |
$79.90
|
| Rate for Payer: Humana KY Medicaid |
$32.33
|
| Rate for Payer: Kentucky WC Medicaid |
$32.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.72
|
| Rate for Payer: Ohio Health Group HMO |
$70.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.86
|
| Rate for Payer: PHCS Commercial |
$90.24
|
| Rate for Payer: United Healthcare All Payer |
$82.72
|
|
|
ZO HYDRATING CREME
|
Professional
|
Both
|
$94.00
|
|
| Hospital Charge Code |
22200168
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$65.80 |
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Multiplan PHCS |
$56.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$65.80
|
| Rate for Payer: UHCCP Medicaid |
$32.90
|
|
|
ZOLADEX 3.6MG IMPLANT
|
Facility
|
IP
|
$6,125.53
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
25002624
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,837.66 |
| Max. Negotiated Rate |
$5,880.51 |
| Rate for Payer: Aetna Commercial |
$4,716.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,777.91
|
| Rate for Payer: Cash Price |
$3,062.76
|
| Rate for Payer: Cigna Commercial |
$5,084.19
|
| Rate for Payer: First Health Commercial |
$5,819.25
|
| Rate for Payer: Humana Commercial |
$5,206.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,022.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,520.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,837.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,390.47
|
| Rate for Payer: Ohio Health Group HMO |
$4,594.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,900.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,329.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,226.62
|
| Rate for Payer: PHCS Commercial |
$5,880.51
|
| Rate for Payer: United Healthcare All Payer |
$5,390.47
|
|
|
ZOLADEX 3.6MG IMPLANT
|
Facility
|
OP
|
$6,125.53
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
25002624
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$734.15 |
| Max. Negotiated Rate |
$5,880.51 |
| Rate for Payer: Aetna Commercial |
$4,716.66
|
| Rate for Payer: Anthem Medicaid |
$2,106.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$734.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,777.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,027.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$991.10
|
| Rate for Payer: Cash Price |
$3,062.76
|
| Rate for Payer: Cash Price |
$3,062.76
|
| Rate for Payer: Cigna Commercial |
$5,084.19
|
| Rate for Payer: First Health Commercial |
$5,819.25
|
| Rate for Payer: Humana Commercial |
$5,206.70
|
| Rate for Payer: Humana KY Medicaid |
$2,106.57
|
| Rate for Payer: Humana Medicare Advantage |
$734.15
|
| Rate for Payer: Kentucky WC Medicaid |
$2,128.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,022.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,520.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$880.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,148.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,390.47
|
| Rate for Payer: Ohio Health Group HMO |
$4,594.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,900.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,329.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,226.62
|
| Rate for Payer: PHCS Commercial |
$5,880.51
|
| Rate for Payer: United Healthcare All Payer |
$5,390.47
|
|
|
ZOLOFT (SERTRALIE)20MG/ML CONC
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 59762006701
|
| Hospital Charge Code |
25003640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| Rate for Payer: Anthem Medicaid |
$1.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.26
|
| Rate for Payer: First Health Commercial |
$4.87
|
| Rate for Payer: Humana Commercial |
$4.36
|
| Rate for Payer: Humana KY Medicaid |
$1.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.51
|
| Rate for Payer: Ohio Health Group HMO |
$3.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.54
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
ZOLOFT (SERTRALIE)20MG/ML CONC
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 59762006701
|
| Hospital Charge Code |
25003640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$3.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cigna Commercial |
$4.26
|
| Rate for Payer: First Health Commercial |
$4.87
|
| Rate for Payer: Humana Commercial |
$4.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.51
|
| Rate for Payer: Ohio Health Group HMO |
$3.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.54
|
| Rate for Payer: PHCS Commercial |
$4.92
|
| Rate for Payer: United Healthcare All Payer |
$4.51
|
|
|
ZOLOFT (SERTRALINE) 100MG/1TAB
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 60687025301
|
| Hospital Charge Code |
25001768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
ZOLOFT (SERTRALINE) 100MG/1TAB
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 60687025301
|
| Hospital Charge Code |
25001768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.20
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
ZOLOFT (SERTRALINE) 50MG/1TAB
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
25001767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
ZOLOFT (SERTRALINE) 50MG/1TAB
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
25001767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
