|
PURAPLY AM WOUND MATRIX 2X4CM
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
PURAPLY AM WOUND MATRIX 5X5CM
|
Facility
|
OP
|
$12,790.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,662.70 |
| Max. Negotiated Rate |
$12,278.40 |
| Rate for Payer: Aetna Commercial |
$9,848.30
|
| Rate for Payer: Anthem Medicaid |
$4,398.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,976.20
|
| Rate for Payer: Cash Price |
$6,395.00
|
| Rate for Payer: Cigna Commercial |
$10,615.70
|
| Rate for Payer: First Health Commercial |
$12,150.50
|
| Rate for Payer: Humana Commercial |
$10,871.50
|
| Rate for Payer: Humana KY Medicaid |
$4,398.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,443.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,487.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,439.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,837.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,486.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,255.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,558.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.90
|
| Rate for Payer: PHCS Commercial |
$12,278.40
|
| Rate for Payer: United Healthcare All Payer |
$11,255.20
|
|
|
PURAPLY AM WOUND MATRIX 5X5CM
|
Facility
|
IP
|
$12,790.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,662.70 |
| Max. Negotiated Rate |
$12,278.40 |
| Rate for Payer: Aetna Commercial |
$9,848.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,976.20
|
| Rate for Payer: Cash Price |
$6,395.00
|
| Rate for Payer: Cigna Commercial |
$10,615.70
|
| Rate for Payer: First Health Commercial |
$12,150.50
|
| Rate for Payer: Humana Commercial |
$10,871.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,487.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,439.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,837.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,255.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,558.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.90
|
| Rate for Payer: PHCS Commercial |
$12,278.40
|
| Rate for Payer: United Healthcare All Payer |
$11,255.20
|
|
|
PURAPLY AM WOUND MATRIX 6X9CM
|
Facility
|
IP
|
$23,524.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,058.18 |
| Max. Negotiated Rate |
$22,583.52 |
| Rate for Payer: Aetna Commercial |
$18,113.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,349.11
|
| Rate for Payer: Cash Price |
$11,762.25
|
| Rate for Payer: Cigna Commercial |
$19,525.34
|
| Rate for Payer: First Health Commercial |
$22,348.28
|
| Rate for Payer: Humana Commercial |
$19,995.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,290.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,361.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,057.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,701.56
|
| Rate for Payer: Ohio Health Group HMO |
$17,643.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,704.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,058.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,292.60
|
| Rate for Payer: PHCS Commercial |
$22,583.52
|
| Rate for Payer: United Healthcare All Payer |
$20,701.56
|
|
|
PURAPLY AM WOUND MATRIX 6X9CM
|
Facility
|
OP
|
$23,524.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,058.18 |
| Max. Negotiated Rate |
$22,583.52 |
| Rate for Payer: Aetna Commercial |
$18,113.86
|
| Rate for Payer: Anthem Medicaid |
$8,090.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,349.11
|
| Rate for Payer: Cash Price |
$11,762.25
|
| Rate for Payer: Cigna Commercial |
$19,525.34
|
| Rate for Payer: First Health Commercial |
$22,348.28
|
| Rate for Payer: Humana Commercial |
$19,995.82
|
| Rate for Payer: Humana KY Medicaid |
$8,090.08
|
| Rate for Payer: Kentucky WC Medicaid |
$8,172.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,290.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,361.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,057.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,252.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,701.56
|
| Rate for Payer: Ohio Health Group HMO |
$17,643.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,704.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,058.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,292.60
|
| Rate for Payer: PHCS Commercial |
$22,583.52
|
| Rate for Payer: United Healthcare All Payer |
$20,701.56
|
|
|
PURE TONE AIR
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
47000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$26.39 |
| Max. Negotiated Rate |
$194.88 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Anthem Medicaid |
$69.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$168.49
|
| Rate for Payer: First Health Commercial |
$192.85
|
| Rate for Payer: Humana Commercial |
$172.55
|
| Rate for Payer: Humana KY Medicaid |
$69.81
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$70.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.64
|
| Rate for Payer: Ohio Health Group HMO |
$152.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.93
|
| Rate for Payer: PHCS Commercial |
$194.88
|
| Rate for Payer: United Healthcare All Payer |
$178.64
|
|
|
PURE TONE AIR
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
47000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$26.39 |
| Max. Negotiated Rate |
$194.88 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$158.34
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$168.49
|
| Rate for Payer: First Health Commercial |
$192.85
|
| Rate for Payer: Humana Commercial |
$172.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.64
|
| Rate for Payer: Ohio Health Group HMO |
$152.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.93
|
| Rate for Payer: PHCS Commercial |
$194.88
|
| Rate for Payer: United Healthcare All Payer |
$178.64
|
|
|
PURE TONE AIR/BONE
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
47000010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem Medicaid |
$70.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Humana KY Medicaid |
$70.84
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$71.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE AIR/BONE
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
47000010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE AIR/BONE(T
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
470T0010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE AIR/BONE(T
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
470T0010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem Medicaid |
$70.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Humana KY Medicaid |
$70.84
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$71.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE AIR(T
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
470T0009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$160.32 |
| Rate for Payer: Aetna Commercial |
$128.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$130.26
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$138.61
|
| Rate for Payer: First Health Commercial |
$158.65
|
| Rate for Payer: Humana Commercial |
$141.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$123.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.96
|
| Rate for Payer: Ohio Health Group HMO |
$125.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.77
|
| Rate for Payer: PHCS Commercial |
$160.32
|
| Rate for Payer: United Healthcare All Payer |
$146.96
|
|
|
PURE TONE AIR(T
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
470T0009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$160.32 |
| Rate for Payer: Aetna Commercial |
$128.59
|
| Rate for Payer: Anthem Medicaid |
$57.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$130.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$138.61
|
| Rate for Payer: First Health Commercial |
$158.65
|
| Rate for Payer: Humana Commercial |
$141.95
|
| Rate for Payer: Humana KY Medicaid |
$57.43
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$58.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$123.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.96
|
| Rate for Payer: Ohio Health Group HMO |
$125.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.77
|
| Rate for Payer: PHCS Commercial |
$160.32
|
| Rate for Payer: United Healthcare All Payer |
$146.96
|
|
|
PURE TONESCREENING & AIR ONL(T
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
470T0008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
PURE TONESCREENING & AIR ONL(T
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
470T0008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem Medicaid |
$12.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Humana KY Medicaid |
$12.04
|
| Rate for Payer: Kentucky WC Medicaid |
$12.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
PURE TONESCREENING & AIR ONLY
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
47000008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
PURE TONESCREENING & AIR ONLY
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
47000008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$15.70
|
| Rate for Payer: Anthem Medicaid |
$12.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.00
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$14.72
|
| Rate for Payer: Healthspan PPO |
$12.85
|
| Rate for Payer: Humana Medicaid |
$12.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.48
|
| Rate for Payer: Molina Healthcare Passport |
$12.24
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.36
|
|
|
PURE TONESCREENING & AIR ONLY
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
47000008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem Medicaid |
$12.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Humana KY Medicaid |
$12.04
|
| Rate for Payer: Kentucky WC Medicaid |
$12.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
PURE TONE THRESH AIR & BONE
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
44000047
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem Medicaid |
$70.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Humana KY Medicaid |
$70.84
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$71.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE THRESH AIR & BONE
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
44000047
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE THRESH & AIR ONLY
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
44000046
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$160.32 |
| Rate for Payer: Aetna Commercial |
$128.59
|
| Rate for Payer: Anthem Medicaid |
$57.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$130.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$138.61
|
| Rate for Payer: First Health Commercial |
$158.65
|
| Rate for Payer: Humana Commercial |
$141.95
|
| Rate for Payer: Humana KY Medicaid |
$57.43
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$58.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$123.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.96
|
| Rate for Payer: Ohio Health Group HMO |
$125.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.77
|
| Rate for Payer: PHCS Commercial |
$160.32
|
| Rate for Payer: United Healthcare All Payer |
$146.96
|
|
|
PURE TONE THRESH & AIR ONLY
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
44000046
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$160.32 |
| Rate for Payer: Aetna Commercial |
$128.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$130.26
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$138.61
|
| Rate for Payer: First Health Commercial |
$158.65
|
| Rate for Payer: Humana Commercial |
$141.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$123.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.96
|
| Rate for Payer: Ohio Health Group HMO |
$125.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.77
|
| Rate for Payer: PHCS Commercial |
$160.32
|
| Rate for Payer: United Healthcare All Payer |
$146.96
|
|
|
PURINETHOL 50MG TABLET
|
Facility
|
IP
|
$17.28
|
|
|
Service Code
|
NDC 54458111
|
| Hospital Charge Code |
25001277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna Commercial |
$13.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.48
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cigna Commercial |
$14.34
|
| Rate for Payer: First Health Commercial |
$16.42
|
| Rate for Payer: Humana Commercial |
$14.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.21
|
| Rate for Payer: Ohio Health Group HMO |
$12.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.36
|
| Rate for Payer: PHCS Commercial |
$16.59
|
| Rate for Payer: United Healthcare All Payer |
$15.21
|
|
|
PURINETHOL 50MG TABLET
|
Facility
|
OP
|
$17.28
|
|
|
Service Code
|
NDC 54458111
|
| Hospital Charge Code |
25001277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna Commercial |
$13.31
|
| Rate for Payer: Anthem Medicaid |
$5.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.48
|
| Rate for Payer: Cash Price |
$8.64
|
| Rate for Payer: Cigna Commercial |
$14.34
|
| Rate for Payer: First Health Commercial |
$16.42
|
| Rate for Payer: Humana Commercial |
$14.69
|
| Rate for Payer: Humana KY Medicaid |
$5.94
|
| Rate for Payer: Kentucky WC Medicaid |
$6.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.21
|
| Rate for Payer: Ohio Health Group HMO |
$12.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.36
|
| Rate for Payer: PHCS Commercial |
$16.59
|
| Rate for Payer: United Healthcare All Payer |
$15.21
|
|
|
PUSHLOCK 2.9*15.5 AR-1923BC
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
