|
ZOLOFT (SERTRAZLINE) 25MG TAB
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
25001769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
ZOLOFT (SERTRAZLINE) 25MG TAB
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
25001769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
ZOMETA 1MG (4MG VIAL)
|
Facility
|
OP
|
$408.75
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
25002456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.62 |
| Max. Negotiated Rate |
$392.40 |
| Rate for Payer: Aetna Commercial |
$314.74
|
| Rate for Payer: Anthem Medicaid |
$140.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$318.82
|
| Rate for Payer: Cash Price |
$204.38
|
| Rate for Payer: Cigna Commercial |
$339.26
|
| Rate for Payer: First Health Commercial |
$388.31
|
| Rate for Payer: Humana Commercial |
$347.44
|
| Rate for Payer: Humana KY Medicaid |
$140.57
|
| Rate for Payer: Kentucky WC Medicaid |
$142.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$335.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$301.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$143.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$359.70
|
| Rate for Payer: Ohio Health Group HMO |
$306.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$327.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$355.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$282.04
|
| Rate for Payer: PHCS Commercial |
$392.40
|
| Rate for Payer: United Healthcare All Payer |
$359.70
|
|
|
ZOMETA 1MG (4MG VIAL)
|
Facility
|
IP
|
$408.75
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
25002456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.62 |
| Max. Negotiated Rate |
$392.40 |
| Rate for Payer: Aetna Commercial |
$314.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$318.82
|
| Rate for Payer: Cash Price |
$204.38
|
| Rate for Payer: Cigna Commercial |
$339.26
|
| Rate for Payer: First Health Commercial |
$388.31
|
| Rate for Payer: Humana Commercial |
$347.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$335.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$301.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$359.70
|
| Rate for Payer: Ohio Health Group HMO |
$306.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$327.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$355.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$282.04
|
| Rate for Payer: PHCS Commercial |
$392.40
|
| Rate for Payer: United Healthcare All Payer |
$359.70
|
|
|
ZONEGRAN 25MG CAPSULE
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 68001024200
|
| Hospital Charge Code |
25001774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.66
|
| Rate for Payer: First Health Commercial |
$4.19
|
| Rate for Payer: Humana Commercial |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| 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 |
$3.88
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Payer |
$3.88
|
|
|
ZONEGRAN 25MG CAPSULE
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 68001024200
|
| Hospital Charge Code |
25001774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.66
|
| Rate for Payer: First Health Commercial |
$4.19
|
| Rate for Payer: Humana Commercial |
$3.75
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| 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 |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.88
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Payer |
$3.88
|
|
|
ZONEGRAN 50MG EQUIVALENT CAP
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 68001024300
|
| Hospital Charge Code |
25003641
|
|
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
|
|
|
ZONEGRAN 50MG EQUIVALENT CAP
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 68001024300
|
| Hospital Charge Code |
25003641
|
|
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
|
|
|
ZONEGRAN (ZONISAMIDE)100MG CAP
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 62756026002
|
| Hospital Charge Code |
25001773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
ZONEGRAN (ZONISAMIDE)100MG CAP
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 62756026002
|
| Hospital Charge Code |
25001773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
ZO OIL CONTROL PADS
|
Professional
|
Both
|
$62.00
|
|
| Hospital Charge Code |
22200162
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Multiplan PHCS |
$37.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$43.40
|
| Rate for Payer: UHCCP Medicaid |
$21.70
|
|
|
ZO OIL CONTROL PADS
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
22200162
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$59.52 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Anthem Medicaid |
$21.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.36
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$51.46
|
| Rate for Payer: First Health Commercial |
$58.90
|
| Rate for Payer: Humana Commercial |
$52.70
|
| Rate for Payer: Humana KY Medicaid |
$21.32
|
| Rate for Payer: Kentucky WC Medicaid |
$21.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.56
|
| Rate for Payer: Ohio Health Group HMO |
$46.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$59.52
|
| Rate for Payer: United Healthcare All Payer |
$54.56
|
|
|
ZO OIL CONTROL PADS
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
22200162
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$59.52 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.36
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$51.46
|
| Rate for Payer: First Health Commercial |
$58.90
|
| Rate for Payer: Humana Commercial |
$52.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.56
|
| Rate for Payer: Ohio Health Group HMO |
$46.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$59.52
|
| Rate for Payer: United Healthcare All Payer |
$54.56
|
|
|
ZO RENEWAL CREAM
|
Professional
|
Both
|
$106.00
|
|
| Hospital Charge Code |
22200166
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$74.20 |
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Multiplan PHCS |
$63.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$74.20
|
| Rate for Payer: UHCCP Medicaid |
$37.10
|
|
|
ZO RENEWAL CREAM
|
Facility
|
IP
|
$106.00
|
|
| Hospital Charge Code |
22200166
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$31.80 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$82.68
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.14
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
ZO RENEWAL CREAM
|
Facility
|
OP
|
$106.00
|
|
| Hospital Charge Code |
22200166
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$31.80 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem Medicaid |
$36.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$82.68
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Humana KY Medicaid |
$36.45
|
| Rate for Payer: Kentucky WC Medicaid |
$36.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.14
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
ZO RETINOL SKIN BRIGHTEN 0.5%
|
Professional
|
Both
|
$104.00
|
|
| Hospital Charge Code |
22200165
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$72.80 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Multiplan PHCS |
$62.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.80
|
| Rate for Payer: UHCCP Medicaid |
$36.40
|
|
|
ZO RETINOL SKIN BRIGHTEN 0.5%
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
22200165
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.12
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$86.32
|
| Rate for Payer: First Health Commercial |
$98.80
|
| Rate for Payer: Humana Commercial |
$88.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.52
|
| Rate for Payer: Ohio Health Group HMO |
$78.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.76
|
| Rate for Payer: PHCS Commercial |
$99.84
|
| Rate for Payer: United Healthcare All Payer |
$91.52
|
|
|
ZO RETINOL SKIN BRIGHTEN 0.5%
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
22200165
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem Medicaid |
$35.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.12
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$86.32
|
| Rate for Payer: First Health Commercial |
$98.80
|
| Rate for Payer: Humana Commercial |
$88.40
|
| Rate for Payer: Humana KY Medicaid |
$35.77
|
| Rate for Payer: Kentucky WC Medicaid |
$36.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.52
|
| Rate for Payer: Ohio Health Group HMO |
$78.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.76
|
| Rate for Payer: PHCS Commercial |
$99.84
|
| Rate for Payer: United Healthcare All Payer |
$91.52
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Facility
|
IP
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
77000049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.46 |
| 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 |
$497.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$428.86
|
| Rate for Payer: PHCS Commercial |
$596.67
|
| Rate for Payer: United Healthcare All Payer |
$546.95
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Professional
|
Both
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
77000049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.59 |
| Max. Negotiated Rate |
$435.07 |
| Rate for Payer: Anthem Medicaid |
$165.59
|
| Rate for Payer: Cash Price |
$310.76
|
| Rate for Payer: Cash Price |
$310.76
|
| Rate for Payer: Healthspan PPO |
$183.00
|
| Rate for Payer: Humana Medicaid |
$165.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$373.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$168.90
|
| Rate for Payer: Molina Healthcare Passport |
$165.59
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.25
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Facility
|
IP
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
770T0049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.46 |
| 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 |
$497.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$428.86
|
| Rate for Payer: PHCS Commercial |
$596.67
|
| Rate for Payer: United Healthcare All Payer |
$546.95
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Facility
|
OP
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
770T0049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.46 |
| 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 |
$497.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$428.86
|
| Rate for Payer: PHCS Commercial |
$596.67
|
| Rate for Payer: United Healthcare All Payer |
$546.95
|
|
|
ZOSTER(SHINGLES)VACC LIVESQINJ
|
Facility
|
OP
|
$621.53
|
|
|
Service Code
|
HCPCS 90736
|
| Hospital Charge Code |
77000049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.46 |
| 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 |
$497.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$428.86
|
| 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 |
$0.04 |
| 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 |
$0.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Payer |
$0.11
|
|
