|
VITALITY HE DR DC/LEAD 8809
|
Facility
|
IP
|
$97,900.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$29,370.00 |
| Max. Negotiated Rate |
$93,984.00 |
| Rate for Payer: Aetna Commercial |
$75,383.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76,362.00
|
| Rate for Payer: Cash Price |
$48,950.00
|
| Rate for Payer: Cigna Commercial |
$81,257.00
|
| Rate for Payer: First Health Commercial |
$93,005.00
|
| Rate for Payer: Humana Commercial |
$83,215.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80,278.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72,250.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29,370.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$86,152.00
|
| Rate for Payer: Ohio Health Group HMO |
$73,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85,173.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,551.00
|
| Rate for Payer: PHCS Commercial |
$93,984.00
|
| Rate for Payer: United Healthcare All Payer |
$86,152.00
|
|
|
VITAMIN A&D OINTMENT 113gm
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 41100081124
|
| Hospital Charge Code |
25004411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$2.86
|
| Rate for Payer: Anthem Medicaid |
$1.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.89
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna Commercial |
$3.08
|
| Rate for Payer: First Health Commercial |
$3.52
|
| Rate for Payer: Humana Commercial |
$3.15
|
| Rate for Payer: Humana KY Medicaid |
$1.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.26
|
| Rate for Payer: Ohio Health Group HMO |
$2.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.56
|
| Rate for Payer: PHCS Commercial |
$3.56
|
| Rate for Payer: United Healthcare All Payer |
$3.26
|
|
|
VITAMIN A&D OINTMENT 113gm
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 41100081124
|
| Hospital Charge Code |
25004411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$2.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.89
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna Commercial |
$3.08
|
| Rate for Payer: First Health Commercial |
$3.52
|
| Rate for Payer: Humana Commercial |
$3.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.26
|
| Rate for Payer: Ohio Health Group HMO |
$2.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.56
|
| Rate for Payer: PHCS Commercial |
$3.56
|
| Rate for Payer: United Healthcare All Payer |
$3.26
|
|
|
VITAMIN A PALMIT50000 U/ML VL
|
Facility
|
OP
|
$1,660.75
|
|
|
Service Code
|
NDC 70199002611
|
| Hospital Charge Code |
25003580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$498.23 |
| Max. Negotiated Rate |
$1,594.32 |
| Rate for Payer: Aetna Commercial |
$1,278.78
|
| Rate for Payer: Anthem Medicaid |
$571.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,295.38
|
| Rate for Payer: Cash Price |
$830.38
|
| Rate for Payer: Cigna Commercial |
$1,378.42
|
| Rate for Payer: First Health Commercial |
$1,577.71
|
| Rate for Payer: Humana Commercial |
$1,411.64
|
| Rate for Payer: Humana KY Medicaid |
$571.13
|
| Rate for Payer: Kentucky WC Medicaid |
$576.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,361.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,225.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$498.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$582.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,461.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,245.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,328.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,145.92
|
| Rate for Payer: PHCS Commercial |
$1,594.32
|
| Rate for Payer: United Healthcare All Payer |
$1,461.46
|
|
|
VITAMIN A PALMIT50000 U/ML VL
|
Facility
|
IP
|
$1,660.75
|
|
|
Service Code
|
NDC 70199002611
|
| Hospital Charge Code |
25003580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$498.23 |
| Max. Negotiated Rate |
$1,594.32 |
| Rate for Payer: Aetna Commercial |
$1,278.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,295.38
|
| Rate for Payer: Cash Price |
$830.38
|
| Rate for Payer: Cigna Commercial |
$1,378.42
|
| Rate for Payer: First Health Commercial |
$1,577.71
|
| Rate for Payer: Humana Commercial |
$1,411.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,361.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,225.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$498.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,461.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,245.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,328.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,145.92
|
| Rate for Payer: PHCS Commercial |
$1,594.32
|
| Rate for Payer: United Healthcare All Payer |
$1,461.46
|
|
|
VITAMIN B12
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 82607
|
| Hospital Charge Code |
30000302
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| 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
|
|
|
VITAMIN B12
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
HCPCS 82607
|
| Hospital Charge Code |
30000302
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$24.36
|
| Rate for Payer: Ambetter Exchange |
$15.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$15.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$15.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.10
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$13.42
|
| Rate for Payer: Healthspan PPO |
$15.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$15.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.08
|
| Rate for Payer: Multiplan PHCS |
$62.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$19.60
|
| Rate for Payer: UHCCP Medicaid |
$36.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$9.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$15.08
|
|
|
VITAMIN B12
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 82607
|
| Hospital Charge Code |
30000302
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem Medicaid |
$15.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.08
|
| Rate for Payer: Cash Price |
$52.00
|
| 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 |
$15.08
|
| Rate for Payer: Humana Medicare Advantage |
$15.08
|
| Rate for Payer: Kentucky WC Medicaid |
$15.23
|
| 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 |
$18.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.38
|
| 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
|
|
|
VITAMIN B12 1000MCG SLG TAB
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 10006070022
|
| Hospital Charge Code |
25001688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
VITAMIN B12 1000MCG SLG TAB
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 10006070022
|
| Hospital Charge Code |
25001688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
VITAMIN B 12 250MCG TABLET
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 50268085315
|
| Hospital Charge Code |
25001686
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| 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 |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
VITAMIN B 12 250MCG TABLET
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 50268085315
|
| Hospital Charge Code |
25001686
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| 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 |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
VITAMIN D 1000 UNIT TABLET
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 20555003300
|
| Hospital Charge Code |
25001689
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
VITAMIN D 1000 UNIT TABLET
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 20555003300
|
| Hospital Charge Code |
25001689
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
VITAMIN D 400 IU TABL
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
NDC 77333094810
|
| Hospital Charge Code |
25001690
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
VITAMIN D 400 IU TABL
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 77333094810
|
| Hospital Charge Code |
25001690
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
VITAMIN D 50000 IU CAPS
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 69452015120
|
| Hospital Charge Code |
25001691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
VITAMIN D 50000 IU CAPS
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 69452015120
|
| Hospital Charge Code |
25001691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.05
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
VITAMIN E 1000 IU CAP
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 904027746
|
| Hospital Charge Code |
25001694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
VITAMIN E 1000 IU CAP
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 904027746
|
| Hospital Charge Code |
25001694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
VITAMIN E (TOCOPHER 100IU/1CAP
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 80681013400
|
| Hospital Charge Code |
25001692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| 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 |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
VITAMIN E (TOCOPHER 100IU/1CAP
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
NDC 80681013400
|
| Hospital Charge Code |
25001692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| 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 |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
VITAMIN E (TOCOPHERO 400U/1CAP
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 77333095110
|
| Hospital Charge Code |
25001693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| 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 |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
VITAMIN E (TOCOPHERO 400U/1CAP
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 77333095110
|
| Hospital Charge Code |
25001693
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| 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 |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
Vitamin K 1mg (10mg IVPB) ANE
|
Facility
|
OP
|
$321.66
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25004146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.50 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna Commercial |
$247.68
|
| Rate for Payer: Anthem Medicaid |
$110.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.89
|
| Rate for Payer: Cash Price |
$160.83
|
| Rate for Payer: Cigna Commercial |
$266.98
|
| Rate for Payer: First Health Commercial |
$305.58
|
| Rate for Payer: Humana Commercial |
$273.41
|
| Rate for Payer: Humana KY Medicaid |
$110.62
|
| Rate for Payer: Kentucky WC Medicaid |
$111.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.06
|
| Rate for Payer: Ohio Health Group HMO |
$241.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$257.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$279.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.95
|
| Rate for Payer: PHCS Commercial |
$308.79
|
| Rate for Payer: United Healthcare All Payer |
$283.06
|
|
