|
TONSIL & ADENOID UNDER 12
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
76101706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSIL & ADENOID UNDER 12(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
761P1706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$209.24 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$423.91
|
| Rate for Payer: Anthem Medicaid |
$209.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$421.16
|
| Rate for Payer: Healthspan PPO |
$357.49
|
| Rate for Payer: Humana Medicaid |
$209.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$376.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.42
|
| Rate for Payer: Molina Healthcare Passport |
$209.24
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.33
|
|
|
TONSILLECTOMY & ADENOID
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
76101707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Humana KY Medicaid |
$240.73
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$243.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$245.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSILLECTOMY & ADENOID
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
76101707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.90 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$443.39
|
| Rate for Payer: Anthem Medicaid |
$236.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$442.70
|
| Rate for Payer: Healthspan PPO |
$373.92
|
| Rate for Payer: Humana Medicaid |
$236.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$391.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$241.64
|
| Rate for Payer: Molina Healthcare Passport |
$236.90
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$239.27
|
|
|
TONSILLECTOMY & ADENOID
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
76101707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSILLECTOMY & ADENOID(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
761P1707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.90 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$443.39
|
| Rate for Payer: Anthem Medicaid |
$236.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$442.70
|
| Rate for Payer: Healthspan PPO |
$373.92
|
| Rate for Payer: Humana Medicaid |
$236.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$391.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$241.64
|
| Rate for Payer: Molina Healthcare Passport |
$236.90
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$239.27
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$3,897.84
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,784.17 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$7,089.80
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,064.14 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
|
|
TONSILLECTOMY OVER 12
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 42826
|
| Hospital Charge Code |
76101709
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Humana KY Medicaid |
$240.73
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$243.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$245.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSILLECTOMY OVER 12
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42826
|
| Hospital Charge Code |
76101709
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.59 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$365.90
|
| Rate for Payer: Anthem Medicaid |
$207.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$364.60
|
| Rate for Payer: Healthspan PPO |
$308.57
|
| Rate for Payer: Humana Medicaid |
$207.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$325.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$211.74
|
| Rate for Payer: Molina Healthcare Passport |
$207.59
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$209.67
|
|
|
TONSILLECTOMY OVER 12
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 42826
|
| Hospital Charge Code |
76101709
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSILLECTOMY OVER 12(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42826
|
| Hospital Charge Code |
761P1709
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.59 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$365.90
|
| Rate for Payer: Anthem Medicaid |
$207.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$364.60
|
| Rate for Payer: Healthspan PPO |
$308.57
|
| Rate for Payer: Humana Medicaid |
$207.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$325.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$211.74
|
| Rate for Payer: Molina Healthcare Passport |
$207.59
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$209.67
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$3,897.84
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,784.17 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$7,089.80
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,064.14 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
|
|
TONSILLECTOMY UNDER 12
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 42825
|
| Hospital Charge Code |
76101708
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
TONSILLECTOMY UNDER 12
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 42825
|
| Hospital Charge Code |
76101708
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.54
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
TONSILLECTOMY UNDER 12
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 42825
|
| Hospital Charge Code |
76101708
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$173.02 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$377.54
|
| Rate for Payer: Anthem Medicaid |
$173.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$371.52
|
| Rate for Payer: Healthspan PPO |
$318.38
|
| Rate for Payer: Humana Medicaid |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$338.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$176.48
|
| Rate for Payer: Molina Healthcare Passport |
$173.02
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.75
|
|
|
TONSILLECTOMY UNDER 12(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 42825
|
| Hospital Charge Code |
761P1708
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$173.02 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$377.54
|
| Rate for Payer: Anthem Medicaid |
$173.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$371.52
|
| Rate for Payer: Healthspan PPO |
$318.38
|
| Rate for Payer: Humana Medicaid |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$338.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$176.48
|
| Rate for Payer: Molina Healthcare Passport |
$173.02
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.75
|
|
|
TOPAMAX SPRINKLE 25 MG CAPSULE
|
Facility
|
IP
|
$9.33
|
|
|
Service Code
|
NDC 68382000514
|
| Hospital Charge Code |
25001564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.86
|
| Rate for Payer: Humana Commercial |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.21
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
TOPAMAX SPRINKLE 25 MG CAPSULE
|
Facility
|
OP
|
$9.33
|
|
|
Service Code
|
NDC 68382000514
|
| Hospital Charge Code |
25001564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem Medicaid |
$3.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.86
|
| Rate for Payer: Humana Commercial |
$7.93
|
| Rate for Payer: Humana KY Medicaid |
$3.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.21
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
TOPAMAX (TOPIRAMATE) 100MG TAB
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 68382014014
|
| Hospital Charge Code |
25001563
|
|
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
|
|
|
TOPAMAX (TOPIRAMATE) 100MG TAB
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 68382014014
|
| Hospital Charge Code |
25001563
|
|
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
|
|
|
TOPAMAX(TOPIRAMATE)25MG TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
25001567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TOPAMAX(TOPIRAMATE)25MG TAB
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
25001567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TOPAMAX(TOPIRAMATE) 50MG CAP
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 68462015360
|
| Hospital Charge Code |
25001566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| 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 |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
