|
VITAMIN D 50000 IU CAPS
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 69452015120
|
| Hospital Charge Code |
25001691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| 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 |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
VITAMIN D 50000 IU CAPS
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 69452015120
|
| Hospital Charge Code |
25001691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| 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 |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
VITAMIN E 1000 IU CAP
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 904027746
|
| Hospital Charge Code |
25001694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| 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 |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
VITAMIN E 1000 IU CAP
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 904027746
|
| Hospital Charge Code |
25001694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| 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 |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
VITAMIN E (TOCOPHER 100IU/1CAP
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
NDC 80681013400
|
| Hospital Charge Code |
25001692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
VITAMIN E (TOCOPHER 100IU/1CAP
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 80681013400
|
| Hospital Charge Code |
25001692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
VITAMIN E (TOCOPHERO 400U/1CAP
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 77333095110
|
| Hospital Charge Code |
25001693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
VITAMIN E (TOCOPHERO 400U/1CAP
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 77333095110
|
| Hospital Charge Code |
25001693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| 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 |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
Vitamin K 1mg (10mg IVPB) ANE
|
Facility
|
IP
|
$204.97
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25004146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.77 |
| Rate for Payer: Aetna Commercial |
$157.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.88
|
| Rate for Payer: Cash Price |
$102.48
|
| Rate for Payer: Cigna Commercial |
$170.13
|
| Rate for Payer: First Health Commercial |
$194.72
|
| Rate for Payer: Humana Commercial |
$174.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.37
|
| Rate for Payer: Ohio Health Group HMO |
$153.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.54
|
| Rate for Payer: PHCS Commercial |
$196.77
|
| Rate for Payer: United Healthcare All Payer |
$180.37
|
|
|
Vitamin K 1mg (10mg IVPB) ANE
|
Facility
|
OP
|
$204.97
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25004146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.77 |
| Rate for Payer: Aetna Commercial |
$157.83
|
| Rate for Payer: Anthem Medicaid |
$70.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.88
|
| Rate for Payer: Cash Price |
$102.48
|
| Rate for Payer: Cigna Commercial |
$170.13
|
| Rate for Payer: First Health Commercial |
$194.72
|
| Rate for Payer: Humana Commercial |
$174.22
|
| Rate for Payer: Humana KY Medicaid |
$70.49
|
| Rate for Payer: Kentucky WC Medicaid |
$71.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.37
|
| Rate for Payer: Ohio Health Group HMO |
$153.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.54
|
| Rate for Payer: PHCS Commercial |
$196.77
|
| Rate for Payer: United Healthcare All Payer |
$180.37
|
|
|
VITAMIN K1, S
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 84597
|
| Hospital Charge Code |
30001825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$106.26
|
| Rate for Payer: Anthem Medicaid |
$13.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.72
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$114.54
|
| Rate for Payer: First Health Commercial |
$131.10
|
| Rate for Payer: Humana Commercial |
$117.30
|
| Rate for Payer: Humana KY Medicaid |
$13.72
|
| Rate for Payer: Humana Medicare Advantage |
$13.72
|
| Rate for Payer: Kentucky WC Medicaid |
$13.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.44
|
| Rate for Payer: Ohio Health Group HMO |
$103.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$132.48
|
| Rate for Payer: United Healthcare All Payer |
$121.44
|
|
|
VITAMIN K1, S
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 84597
|
| Hospital Charge Code |
30001825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.94 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$106.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.81
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$114.54
|
| Rate for Payer: First Health Commercial |
$131.10
|
| Rate for Payer: Humana Commercial |
$117.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.44
|
| Rate for Payer: Ohio Health Group HMO |
$103.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$132.48
|
| Rate for Payer: United Healthcare All Payer |
$121.44
|
|
|
VITB12(CYANOCOBALAMIN)100MCG T
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 50268085215
|
| Hospital Charge Code |
25001683
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| 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 |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
VITB12(CYANOCOBALAMIN)100MCG T
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 50268085215
|
| Hospital Charge Code |
25001683
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| 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 |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
VITK MG (2.5MG/2.5ML ORAL SOL)
|
Facility
|
IP
|
$292.42
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$280.72 |
| Rate for Payer: Aetna Commercial |
$225.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$228.09
|
| Rate for Payer: Cash Price |
$146.21
|
| Rate for Payer: Cigna Commercial |
$242.71
|
| Rate for Payer: First Health Commercial |
$277.80
|
| Rate for Payer: Humana Commercial |
$248.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$257.33
|
| Rate for Payer: Ohio Health Group HMO |
$219.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.65
|
| Rate for Payer: PHCS Commercial |
$280.72
|
| Rate for Payer: United Healthcare All Payer |
$257.33
|
|
|
VITK MG (2.5MG/2.5ML ORAL SOL)
|
Facility
|
OP
|
$292.42
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$280.72 |
| Rate for Payer: Aetna Commercial |
$225.16
|
| Rate for Payer: Anthem Medicaid |
$100.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$228.09
|
| Rate for Payer: Cash Price |
$146.21
|
| Rate for Payer: Cigna Commercial |
$242.71
|
| Rate for Payer: First Health Commercial |
$277.80
|
| Rate for Payer: Humana Commercial |
$248.56
|
| Rate for Payer: Humana KY Medicaid |
$100.56
|
| Rate for Payer: Kentucky WC Medicaid |
$101.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$257.33
|
| Rate for Payer: Ohio Health Group HMO |
$219.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.65
|
| Rate for Payer: PHCS Commercial |
$280.72
|
| Rate for Payer: United Healthcare All Payer |
$257.33
|
|
|
VITOSS BA2X BONE GRAFT 10CC
|
Facility
|
OP
|
$22,860.20
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,971.83 |
| Max. Negotiated Rate |
$21,945.79 |
| Rate for Payer: Aetna Commercial |
$17,602.35
|
| Rate for Payer: Anthem Medicaid |
$7,861.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,830.96
|
| Rate for Payer: Cash Price |
$11,430.10
|
| Rate for Payer: Cigna Commercial |
$18,973.97
|
| Rate for Payer: First Health Commercial |
$21,717.19
|
| Rate for Payer: Humana Commercial |
$19,431.17
|
| Rate for Payer: Humana KY Medicaid |
$7,861.62
|
| Rate for Payer: Kentucky WC Medicaid |
$7,941.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,745.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,870.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,858.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,019.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,116.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,145.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,572.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,971.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,086.66
|
| Rate for Payer: PHCS Commercial |
$21,945.79
|
| Rate for Payer: United Healthcare All Payer |
$20,116.98
|
|
|
VITOSS BA2X BONE GRAFT 10CC
|
Facility
|
IP
|
$22,860.20
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,971.83 |
| Max. Negotiated Rate |
$21,945.79 |
| Rate for Payer: Aetna Commercial |
$17,602.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,830.96
|
| Rate for Payer: Cash Price |
$11,430.10
|
| Rate for Payer: Cigna Commercial |
$18,973.97
|
| Rate for Payer: First Health Commercial |
$21,717.19
|
| Rate for Payer: Humana Commercial |
$19,431.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,745.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,870.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,858.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,116.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,145.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,572.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,971.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,086.66
|
| Rate for Payer: PHCS Commercial |
$21,945.79
|
| Rate for Payer: United Healthcare All Payer |
$20,116.98
|
|
|
VITOSS BA2X BONE GRAFT 1.2CC
|
Facility
|
OP
|
$5,490.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$713.70 |
| Max. Negotiated Rate |
$5,270.40 |
| Rate for Payer: Aetna Commercial |
$4,227.30
|
| Rate for Payer: Anthem Medicaid |
$1,888.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,282.20
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cigna Commercial |
$4,556.70
|
| Rate for Payer: First Health Commercial |
$5,215.50
|
| Rate for Payer: Humana Commercial |
$4,666.50
|
| Rate for Payer: Humana KY Medicaid |
$1,888.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,907.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,501.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,051.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,647.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,925.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,831.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,117.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,098.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$713.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,701.90
|
| Rate for Payer: PHCS Commercial |
$5,270.40
|
| Rate for Payer: United Healthcare All Payer |
$4,831.20
|
|
|
VITOSS BA2X BONE GRAFT 1.2CC
|
Facility
|
IP
|
$5,490.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$713.70 |
| Max. Negotiated Rate |
$5,270.40 |
| Rate for Payer: Aetna Commercial |
$4,227.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,282.20
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cigna Commercial |
$4,556.70
|
| Rate for Payer: First Health Commercial |
$5,215.50
|
| Rate for Payer: Humana Commercial |
$4,666.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,501.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,051.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,647.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,831.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,117.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,098.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$713.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,701.90
|
| Rate for Payer: PHCS Commercial |
$5,270.40
|
| Rate for Payer: United Healthcare All Payer |
$4,831.20
|
|
|
VITOSS BA2X BONE GRAFT 2.5CC
|
Facility
|
OP
|
$7,957.45
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,034.47 |
| Max. Negotiated Rate |
$7,639.15 |
| Rate for Payer: Aetna Commercial |
$6,127.24
|
| Rate for Payer: Anthem Medicaid |
$2,736.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,206.81
|
| Rate for Payer: Cash Price |
$3,978.72
|
| Rate for Payer: Cigna Commercial |
$6,604.68
|
| Rate for Payer: First Health Commercial |
$7,559.58
|
| Rate for Payer: Humana Commercial |
$6,763.83
|
| Rate for Payer: Humana KY Medicaid |
$2,736.57
|
| Rate for Payer: Kentucky WC Medicaid |
$2,764.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,525.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,872.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,387.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,791.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,002.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,968.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,591.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,034.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.81
|
| Rate for Payer: PHCS Commercial |
$7,639.15
|
| Rate for Payer: United Healthcare All Payer |
$7,002.56
|
|
|
VITOSS BA2X BONE GRAFT 2.5CC
|
Facility
|
IP
|
$7,957.45
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,034.47 |
| Max. Negotiated Rate |
$7,639.15 |
| Rate for Payer: Aetna Commercial |
$6,127.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,206.81
|
| Rate for Payer: Cash Price |
$3,978.72
|
| Rate for Payer: Cigna Commercial |
$6,604.68
|
| Rate for Payer: First Health Commercial |
$7,559.58
|
| Rate for Payer: Humana Commercial |
$6,763.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,525.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,872.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,387.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,002.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,968.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,591.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,034.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.81
|
| Rate for Payer: PHCS Commercial |
$7,639.15
|
| Rate for Payer: United Healthcare All Payer |
$7,002.56
|
|
|
VITOSS BA2X BONE GRAFT 5CC
|
Facility
|
OP
|
$12,695.10
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,650.36 |
| Max. Negotiated Rate |
$12,187.30 |
| Rate for Payer: Aetna Commercial |
$9,775.23
|
| Rate for Payer: Anthem Medicaid |
$4,365.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,902.18
|
| Rate for Payer: Cash Price |
$6,347.55
|
| Rate for Payer: Cigna Commercial |
$10,536.93
|
| Rate for Payer: First Health Commercial |
$12,060.34
|
| Rate for Payer: Humana Commercial |
$10,790.84
|
| Rate for Payer: Humana KY Medicaid |
$4,365.84
|
| Rate for Payer: Kentucky WC Medicaid |
$4,410.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,409.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,368.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,808.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,453.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,171.69
|
| Rate for Payer: Ohio Health Group HMO |
$9,521.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,539.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,650.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,935.48
|
| Rate for Payer: PHCS Commercial |
$12,187.30
|
| Rate for Payer: United Healthcare All Payer |
$11,171.69
|
|
|
VITOSS BA2X BONE GRAFT 5CC
|
Facility
|
IP
|
$12,695.10
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,650.36 |
| Max. Negotiated Rate |
$12,187.30 |
| Rate for Payer: Aetna Commercial |
$9,775.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,902.18
|
| Rate for Payer: Cash Price |
$6,347.55
|
| Rate for Payer: Cigna Commercial |
$10,536.93
|
| Rate for Payer: First Health Commercial |
$12,060.34
|
| Rate for Payer: Humana Commercial |
$10,790.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,409.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,368.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,808.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,171.69
|
| Rate for Payer: Ohio Health Group HMO |
$9,521.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,539.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,650.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,935.48
|
| Rate for Payer: PHCS Commercial |
$12,187.30
|
| Rate for Payer: United Healthcare All Payer |
$11,171.69
|
|
|
VITOSS CANISTER 15CC 1-4MM
|
Facility
|
OP
|
$7,107.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
27000053
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$923.91 |
| Max. Negotiated Rate |
$6,822.72 |
| Rate for Payer: Aetna Commercial |
$5,472.39
|
| Rate for Payer: Anthem Medicaid |
$2,444.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,543.46
|
| Rate for Payer: Cash Price |
$3,553.50
|
| Rate for Payer: Cigna Commercial |
$5,898.81
|
| Rate for Payer: First Health Commercial |
$6,751.65
|
| Rate for Payer: Humana Commercial |
$6,040.95
|
| Rate for Payer: Humana KY Medicaid |
$2,444.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,132.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,493.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,254.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,330.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,421.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,203.17
|
| Rate for Payer: PHCS Commercial |
$6,822.72
|
| Rate for Payer: United Healthcare All Payer |
$6,254.16
|
|
