|
PUNCH BX SKIN EA SEP/ADDL(P
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 11105
|
| Hospital Charge Code |
761P2568
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$12.98 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Ambetter Exchange |
$23.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$12.98
|
| Rate for Payer: Anthem Medicaid |
$46.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.72
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$96.98
|
| Rate for Payer: Humana Medicaid |
$46.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.59
|
| Rate for Payer: Molina Healthcare Passport |
$46.66
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.11
|
| Rate for Payer: UHCCP Medicaid |
$13.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$47.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.93
|
|
|
PUNCH BX SKIN EA SEP/ADDL(T
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
HCPCS 11105
|
| Hospital Charge Code |
761T2568
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$282.24 |
| Rate for Payer: Aetna Commercial |
$226.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$229.32
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$244.02
|
| Rate for Payer: First Health Commercial |
$279.30
|
| Rate for Payer: Humana Commercial |
$249.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$216.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$258.72
|
| Rate for Payer: Ohio Health Group HMO |
$220.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.86
|
| Rate for Payer: PHCS Commercial |
$282.24
|
| Rate for Payer: United Healthcare All Payer |
$258.72
|
|
|
PUNCH BX SKIN EA SEP/ADDL(T
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
HCPCS 11105
|
| Hospital Charge Code |
761T2568
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$282.24 |
| Rate for Payer: Aetna Commercial |
$226.38
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$229.32
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$244.02
|
| Rate for Payer: First Health Commercial |
$279.30
|
| Rate for Payer: Humana Commercial |
$249.90
|
| Rate for Payer: Humana KY Medicaid |
$101.11
|
| Rate for Payer: Kentucky WC Medicaid |
$102.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$216.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$258.72
|
| Rate for Payer: Ohio Health Group HMO |
$220.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.86
|
| Rate for Payer: PHCS Commercial |
$282.24
|
| Rate for Payer: United Healthcare All Payer |
$258.72
|
|
|
PUNCH BX SKIN SINGLE LESION
|
Facility
|
IP
|
$836.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
76100035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$250.80 |
| Max. Negotiated Rate |
$802.56 |
| Rate for Payer: Aetna Commercial |
$643.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.08
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$693.88
|
| Rate for Payer: First Health Commercial |
$794.20
|
| Rate for Payer: Humana Commercial |
$710.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$685.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$735.68
|
| Rate for Payer: Ohio Health Group HMO |
$627.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.84
|
| Rate for Payer: PHCS Commercial |
$802.56
|
| Rate for Payer: United Healthcare All Payer |
$735.68
|
|
|
PUNCH BX SKIN SINGLE LESION
|
Facility
|
OP
|
$836.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
76100035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.50 |
| Max. Negotiated Rate |
$802.56 |
| Rate for Payer: Aetna Commercial |
$643.72
|
| Rate for Payer: Anthem Medicaid |
$287.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$693.88
|
| Rate for Payer: First Health Commercial |
$794.20
|
| Rate for Payer: Humana Commercial |
$710.60
|
| Rate for Payer: Humana KY Medicaid |
$287.50
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$290.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$685.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$293.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$735.68
|
| Rate for Payer: Ohio Health Group HMO |
$627.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.84
|
| Rate for Payer: PHCS Commercial |
$802.56
|
| Rate for Payer: United Healthcare All Payer |
$735.68
|
|
|
PUNCH BX SKIN SINGLE LESION
|
Professional
|
Both
|
$836.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
76100035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$501.60 |
| Rate for Payer: Ambetter Exchange |
$44.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.09
|
| Rate for Payer: Anthem Medicaid |
$94.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$44.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$44.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$52.85
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cash Price |
$418.00
|
| Rate for Payer: Cigna Commercial |
$196.96
|
| Rate for Payer: Humana Medicaid |
$94.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$44.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.55
|
| Rate for Payer: Molina Healthcare Passport |
$94.66
|
| Rate for Payer: Multiplan PHCS |
$501.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$57.25
|
| Rate for Payer: UHCCP Medicaid |
$32.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$44.04
|
|
|
PUNCH BX SKIN SINGLE LESION(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
761P0035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$196.96 |
| Rate for Payer: Ambetter Exchange |
$44.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.09
|
| Rate for Payer: Anthem Medicaid |
$94.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$44.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$44.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$52.85
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$196.96
|
| Rate for Payer: Humana Medicaid |
$94.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$44.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.55
|
| Rate for Payer: Molina Healthcare Passport |
$94.66
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$57.25
|
| Rate for Payer: UHCCP Medicaid |
$32.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$44.04
|
|
|
PUNCH BX SKIN SINGLE LESION(T
|
Facility
|
OP
|
$586.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
761T0035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.53 |
| Max. Negotiated Rate |
$562.56 |
| Rate for Payer: Aetna Commercial |
$451.22
|
| Rate for Payer: Anthem Medicaid |
$201.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$457.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cigna Commercial |
$486.38
|
| Rate for Payer: First Health Commercial |
$556.70
|
| Rate for Payer: Humana Commercial |
$498.10
|
| Rate for Payer: Humana KY Medicaid |
$201.53
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$203.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$480.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$432.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$205.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$515.68
|
| Rate for Payer: Ohio Health Group HMO |
$439.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$404.34
|
| Rate for Payer: PHCS Commercial |
$562.56
|
| Rate for Payer: United Healthcare All Payer |
$515.68
|
|
|
PUNCH BX SKIN SINGLE LESION(T
|
Facility
|
IP
|
$586.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
761T0035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.80 |
| Max. Negotiated Rate |
$562.56 |
| Rate for Payer: Aetna Commercial |
$451.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$457.08
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cigna Commercial |
$486.38
|
| Rate for Payer: First Health Commercial |
$556.70
|
| Rate for Payer: Humana Commercial |
$498.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$480.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$432.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$515.68
|
| Rate for Payer: Ohio Health Group HMO |
$439.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$404.34
|
| Rate for Payer: PHCS Commercial |
$562.56
|
| Rate for Payer: United Healthcare All Payer |
$515.68
|
|
|
PURAPLY 2*2
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
PURAPLY 2*2
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
PURAPLY AM WOUND MATRIX 16MM D
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
PURAPLY AM WOUND MATRIX 16MM D
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
PURAPLY AM WOUND MATRIX 2X2CM
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
PURAPLY AM WOUND MATRIX 2X2CM
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
PURAPLY AM WOUND MATRIX 2X4CM
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
PURAPLY AM WOUND MATRIX 2X4CM
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
PURAPLY AM WOUND MATRIX 5X5CM
|
Facility
|
IP
|
$13,042.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
PURAPLY AM WOUND MATRIX 5X5CM
|
Facility
|
OP
|
$13,042.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem Medicaid |
$4,485.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Humana KY Medicaid |
$4,485.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,530.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,575.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
PURAPLY AM WOUND MATRIX 6X9CM
|
Facility
|
OP
|
$24,237.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,271.25 |
| Max. Negotiated Rate |
$23,268.00 |
| Rate for Payer: Aetna Commercial |
$18,662.88
|
| Rate for Payer: Anthem Medicaid |
$8,335.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,905.25
|
| Rate for Payer: Cash Price |
$12,118.75
|
| Rate for Payer: Cigna Commercial |
$20,117.12
|
| Rate for Payer: First Health Commercial |
$23,025.62
|
| Rate for Payer: Humana Commercial |
$20,601.88
|
| Rate for Payer: Humana KY Medicaid |
$8,335.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8,420.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,874.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,887.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,271.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,502.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,329.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,178.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,390.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,086.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,723.88
|
| Rate for Payer: PHCS Commercial |
$23,268.00
|
| Rate for Payer: United Healthcare All Payer |
$21,329.00
|
|
|
PURAPLY AM WOUND MATRIX 6X9CM
|
Facility
|
IP
|
$24,237.50
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
25003714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,271.25 |
| Max. Negotiated Rate |
$23,268.00 |
| Rate for Payer: Aetna Commercial |
$18,662.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,905.25
|
| Rate for Payer: Cash Price |
$12,118.75
|
| Rate for Payer: Cigna Commercial |
$20,117.12
|
| Rate for Payer: First Health Commercial |
$23,025.62
|
| Rate for Payer: Humana Commercial |
$20,601.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,874.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,887.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,271.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,329.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,178.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,390.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,086.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,723.88
|
| Rate for Payer: PHCS Commercial |
$23,268.00
|
| Rate for Payer: United Healthcare All Payer |
$21,329.00
|
|
|
PURE TONE AIR
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
47000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$53.40 |
| Max. Negotiated Rate |
$170.88 |
| Rate for Payer: Aetna Commercial |
$137.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$138.84
|
| Rate for Payer: Cash Price |
$89.00
|
| Rate for Payer: Cigna Commercial |
$147.74
|
| Rate for Payer: First Health Commercial |
$169.10
|
| Rate for Payer: Humana Commercial |
$151.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$156.64
|
| Rate for Payer: Ohio Health Group HMO |
$133.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.82
|
| Rate for Payer: PHCS Commercial |
$170.88
|
| Rate for Payer: United Healthcare All Payer |
$156.64
|
|
|
PURE TONE AIR
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
47000009
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$61.21 |
| Max. Negotiated Rate |
$170.88 |
| Rate for Payer: Aetna Commercial |
$137.06
|
| Rate for Payer: Anthem Medicaid |
$61.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$138.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$89.00
|
| Rate for Payer: Cash Price |
$89.00
|
| Rate for Payer: Cigna Commercial |
$147.74
|
| Rate for Payer: First Health Commercial |
$169.10
|
| Rate for Payer: Humana Commercial |
$151.30
|
| Rate for Payer: Humana KY Medicaid |
$61.21
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$61.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$156.64
|
| Rate for Payer: Ohio Health Group HMO |
$133.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.82
|
| Rate for Payer: PHCS Commercial |
$170.88
|
| Rate for Payer: United Healthcare All Payer |
$156.64
|
|
|
PURE TONE AIR/BONE
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
47000010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna Commercial |
$43.33
|
| Rate for Payer: Ambetter Exchange |
$42.77
|
| Rate for Payer: Anthem Medicaid |
$18.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.32
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Healthspan PPO |
$35.46
|
| Rate for Payer: Humana Medicaid |
$18.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.97
|
| Rate for Payer: Molina Healthcare Passport |
$18.60
|
| Rate for Payer: Multiplan PHCS |
$131.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.60
|
| Rate for Payer: UHCCP Medicaid |
$76.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.77
|
|
|
PURE TONE AIR/BONE
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
47000010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$210.24 |
| Rate for Payer: Aetna Commercial |
$168.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.82
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$181.77
|
| Rate for Payer: First Health Commercial |
$208.05
|
| Rate for Payer: Humana Commercial |
$186.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.72
|
| Rate for Payer: Ohio Health Group HMO |
$164.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$175.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.11
|
| Rate for Payer: PHCS Commercial |
$210.24
|
| Rate for Payer: United Healthcare All Payer |
$192.72
|
|
