|
TOBI(TOBRAMYCIN SOLN)300MG/5ML
|
Facility
|
OP
|
$28.75
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
25002520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$22.14
|
| Rate for Payer: Anthem Medicaid |
$9.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.43
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cigna Commercial |
$23.86
|
| Rate for Payer: First Health Commercial |
$27.31
|
| Rate for Payer: Humana Commercial |
$24.44
|
| Rate for Payer: Humana KY Medicaid |
$9.89
|
| Rate for Payer: Kentucky WC Medicaid |
$9.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.30
|
| Rate for Payer: Ohio Health Group HMO |
$21.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
| Rate for Payer: PHCS Commercial |
$27.60
|
| Rate for Payer: United Healthcare All Payer |
$25.30
|
|
|
TOBI(TOBRAMYCIN SOLN)300MG/5ML
|
Facility
|
IP
|
$28.75
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
25002520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$22.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.43
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cigna Commercial |
$23.86
|
| Rate for Payer: First Health Commercial |
$27.31
|
| Rate for Payer: Humana Commercial |
$24.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.30
|
| Rate for Payer: Ohio Health Group HMO |
$21.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.84
|
| Rate for Payer: PHCS Commercial |
$27.60
|
| Rate for Payer: United Healthcare All Payer |
$25.30
|
|
|
TOBRADEX EYE DROPS 2.5 ML
|
Facility
|
OP
|
$3.78
|
|
|
Service Code
|
NDC 574403125
|
| Hospital Charge Code |
25003526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Anthem Medicaid |
$1.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna Commercial |
$3.14
|
| Rate for Payer: First Health Commercial |
$3.59
|
| Rate for Payer: Humana Commercial |
$3.21
|
| Rate for Payer: Humana KY Medicaid |
$1.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.33
|
| Rate for Payer: Ohio Health Group HMO |
$2.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.61
|
| Rate for Payer: PHCS Commercial |
$3.63
|
| Rate for Payer: United Healthcare All Payer |
$3.33
|
|
|
TOBRADEX EYE DROPS 2.5 ML
|
Facility
|
IP
|
$3.78
|
|
|
Service Code
|
NDC 574403125
|
| Hospital Charge Code |
25003526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.95
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna Commercial |
$3.14
|
| Rate for Payer: First Health Commercial |
$3.59
|
| Rate for Payer: Humana Commercial |
$3.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.33
|
| Rate for Payer: Ohio Health Group HMO |
$2.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.61
|
| Rate for Payer: PHCS Commercial |
$3.63
|
| Rate for Payer: United Healthcare All Payer |
$3.33
|
|
|
TOBRAMYCIN (PEAK)
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 80200
|
| Hospital Charge Code |
30000050
|
|
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
|
|
|
TOBRAMYCIN (PEAK)
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 80200
|
| Hospital Charge Code |
30000050
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem Medicaid |
$16.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.13
|
| 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 |
$16.13
|
| Rate for Payer: Humana Medicare Advantage |
$16.13
|
| Rate for Payer: Kentucky WC Medicaid |
$16.29
|
| 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 |
$19.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.45
|
| 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
|
|
|
TOBREX (TOBRAMYCIN).3% O 3.5GM
|
Facility
|
IP
|
$29.50
|
|
|
Service Code
|
NDC 78081301
|
| Hospital Charge Code |
25001557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$28.32 |
| Rate for Payer: Aetna Commercial |
$22.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.01
|
| Rate for Payer: Cash Price |
$14.75
|
| Rate for Payer: Cigna Commercial |
$24.48
|
| Rate for Payer: First Health Commercial |
$28.02
|
| Rate for Payer: Humana Commercial |
$25.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.96
|
| Rate for Payer: Ohio Health Group HMO |
$22.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.36
|
| Rate for Payer: PHCS Commercial |
$28.32
|
| Rate for Payer: United Healthcare All Payer |
$25.96
|
|
|
TOBREX (TOBRAMYCIN).3% O 3.5GM
|
Facility
|
OP
|
$29.50
|
|
|
Service Code
|
NDC 78081301
|
| Hospital Charge Code |
25001557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$28.32 |
| Rate for Payer: Aetna Commercial |
$22.71
|
| Rate for Payer: Anthem Medicaid |
$10.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.01
|
| Rate for Payer: Cash Price |
$14.75
|
| Rate for Payer: Cigna Commercial |
$24.48
|
| Rate for Payer: First Health Commercial |
$28.02
|
| Rate for Payer: Humana Commercial |
$25.07
|
| Rate for Payer: Humana KY Medicaid |
$10.15
|
| Rate for Payer: Kentucky WC Medicaid |
$10.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.96
|
| Rate for Payer: Ohio Health Group HMO |
$22.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.36
|
| Rate for Payer: PHCS Commercial |
$28.32
|
| Rate for Payer: United Healthcare All Payer |
$25.96
|
|
|
TOBREX (TOBRAMYCIN).3% OPH 5ML
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
25001558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna Commercial |
$0.45
|
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem Medicaid |
$0.20
|
| Rate for Payer: Anthem Medicaid |
$0.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: Cigna Commercial |
$0.49
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.56
|
| Rate for Payer: Humana Commercial |
$0.50
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Humana KY Medicaid |
$0.20
|
| Rate for Payer: Humana KY Medicaid |
$0.28
|
| Rate for Payer: Kentucky WC Medicaid |
$0.28
|
| Rate for Payer: Kentucky WC Medicaid |
$0.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.44
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.55
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: PHCS Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
| Rate for Payer: United Healthcare All Payer |
$0.52
|
|
|
TOBREX (TOBRAMYCIN).3% OPH 5ML
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
25001558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna Commercial |
$0.45
|
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.49
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.56
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Humana Commercial |
$0.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.44
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$0.57
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
TOFRANIL 10MG TAB
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 69584042510
|
| Hospital Charge Code |
25001560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
TOFRANIL 10MG TAB
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 69584042510
|
| Hospital Charge Code |
25001560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
TOFRANIL (IMIPRAMINE 25MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 69315013401
|
| Hospital Charge Code |
25001559
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
TOFRANIL (IMIPRAMINE 25MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 69315013401
|
| Hospital Charge Code |
25001559
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
TONSIL & ADENOID UNDER 12
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
76101706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$209.24 |
| Max. Negotiated Rate |
$423.91 |
| Rate for Payer: Aetna Commercial |
$423.91
|
| Rate for Payer: Ambetter Exchange |
$276.52
|
| Rate for Payer: Anthem Medicaid |
$209.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.82
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$276.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.52
|
| 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 |
$359.48
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.52
|
|
|
TONSIL & ADENOID UNDER 12
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
76101706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.00 |
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSIL & ADENOID UNDER 12
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
76101706
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.73 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| 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 |
$5,465.95
|
| 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 |
$6,559.14
|
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| 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 |
$423.91 |
| Rate for Payer: Aetna Commercial |
$423.91
|
| Rate for Payer: Ambetter Exchange |
$276.52
|
| Rate for Payer: Anthem Medicaid |
$209.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.82
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$276.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.52
|
| 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 |
$359.48
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.52
|
|
|
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 |
$443.39 |
| Rate for Payer: Aetna Commercial |
$443.39
|
| Rate for Payer: Ambetter Exchange |
$288.20
|
| Rate for Payer: Anthem Medicaid |
$236.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$288.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$288.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.84
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$288.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$288.20
|
| 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 |
$374.66
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$239.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$288.20
|
|
|
TONSILLECTOMY & ADENOID
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
76101707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.00 |
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
TONSILLECTOMY & ADENOID
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
76101707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.73 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| 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 |
$2,996.53
|
| 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 |
$3,595.84
|
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| 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 |
$443.39 |
| Rate for Payer: Aetna Commercial |
$443.39
|
| Rate for Payer: Ambetter Exchange |
$288.20
|
| Rate for Payer: Anthem Medicaid |
$236.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$288.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$288.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.84
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$288.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$288.20
|
| 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 |
$374.66
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$239.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$288.20
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$4,195.14
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,996.53 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$7,652.33
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,465.95 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
|
|
TONSILLECTOMY OVER 12
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 42826
|
| Hospital Charge Code |
76101709
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.73 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| 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 |
$2,996.53
|
| 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 |
$3,595.84
|
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
