|
PURE TONE AIR/BONE
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
47000010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$75.31 |
| Max. Negotiated Rate |
$210.24 |
| Rate for Payer: Aetna Commercial |
$168.63
|
| Rate for Payer: Anthem Medicaid |
$75.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$109.50
|
| 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: Humana KY Medicaid |
$75.31
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$76.08
|
| 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 |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.83
|
| 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
|
|
|
PURE TONE AIR/BONE(T
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
470T0010
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$75.31 |
| Max. Negotiated Rate |
$210.24 |
| Rate for Payer: Aetna Commercial |
$168.63
|
| Rate for Payer: Anthem Medicaid |
$75.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$109.50
|
| 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: Humana KY Medicaid |
$75.31
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$76.08
|
| 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 |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.83
|
| 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
|
|
|
PURE TONE AIR/BONE(T
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
470T0010
|
|
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
|
|
|
PURE TONE AIR(T
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
470T0009
|
|
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(T
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
470T0009
|
|
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 TONESCREENING & AIR ONL(T
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
470T0008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Aetna Commercial |
$27.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.08
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.88
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: Humana Commercial |
$30.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.68
|
| Rate for Payer: Ohio Health Group HMO |
$27.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.84
|
| Rate for Payer: PHCS Commercial |
$34.56
|
| Rate for Payer: United Healthcare All Payer |
$31.68
|
|
|
PURE TONESCREENING & AIR ONL(T
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
470T0008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Aetna Commercial |
$27.72
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.08
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.88
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: Humana Commercial |
$30.60
|
| Rate for Payer: Humana KY Medicaid |
$12.38
|
| Rate for Payer: Kentucky WC Medicaid |
$12.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.68
|
| Rate for Payer: Ohio Health Group HMO |
$27.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.84
|
| Rate for Payer: PHCS Commercial |
$34.56
|
| Rate for Payer: United Healthcare All Payer |
$31.68
|
|
|
PURE TONESCREENING & AIR ONLY
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
47000008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Aetna Commercial |
$27.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.08
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.88
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: Humana Commercial |
$30.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.68
|
| Rate for Payer: Ohio Health Group HMO |
$27.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.84
|
| Rate for Payer: PHCS Commercial |
$34.56
|
| Rate for Payer: United Healthcare All Payer |
$31.68
|
|
|
PURE TONESCREENING & AIR ONLY
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
47000008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna Commercial |
$15.70
|
| Rate for Payer: Anthem Medicaid |
$12.24
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| 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 |
$21.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.20
|
| Rate for Payer: UHCCP Medicaid |
$12.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.36
|
|
|
PURE TONESCREENING & AIR ONLY
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS 92551
|
| Hospital Charge Code |
47000008
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Aetna Commercial |
$27.72
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.08
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$29.88
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: Humana Commercial |
$30.60
|
| Rate for Payer: Humana KY Medicaid |
$12.38
|
| Rate for Payer: Kentucky WC Medicaid |
$12.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.68
|
| Rate for Payer: Ohio Health Group HMO |
$27.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.84
|
| Rate for Payer: PHCS Commercial |
$34.56
|
| Rate for Payer: United Healthcare All Payer |
$31.68
|
|
|
PURE TONE THRESH AIR & BONE
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
HCPCS 92553
|
| Hospital Charge Code |
44000047
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$70.84 |
| Max. Negotiated Rate |
$202.40 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem Medicaid |
$70.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| 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 |
$144.57
|
| 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 |
$173.48
|
| 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 |
$164.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$179.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.14
|
| 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 |
$61.80 |
| 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 |
$164.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$179.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.14
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
PURE TONE THRESH & AIR ONLY
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
44000046
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$51.90 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$119.37
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
PURE TONE THRESH & AIR ONLY
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
44000046
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$103.80 |
| Rate for Payer: Aetna Commercial |
$32.29
|
| Rate for Payer: Ambetter Exchange |
$35.40
|
| Rate for Payer: Anthem Medicaid |
$12.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.48
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$31.41
|
| Rate for Payer: Healthspan PPO |
$26.42
|
| Rate for Payer: Humana Medicaid |
$12.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.48
|
| Rate for Payer: Molina Healthcare Passport |
$12.24
|
| Rate for Payer: Multiplan PHCS |
$103.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.02
|
| Rate for Payer: UHCCP Medicaid |
$60.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.40
|
|
|
PURE TONE THRESH & AIR ONLY
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
44000046
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$59.49 |
| Max. Negotiated Rate |
$166.74 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$119.37
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
PURINETHOL 50MG TABLET
|
Facility
|
OP
|
$17.28
|
|
|
Service Code
|
NDC 54458111
|
| Hospital Charge Code |
25001277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| 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 |
$13.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.92
|
| Rate for Payer: PHCS Commercial |
$16.59
|
| Rate for Payer: United Healthcare All Payer |
$15.21
|
|
|
PURINETHOL 50MG TABLET
|
Facility
|
IP
|
$17.28
|
|
|
Service Code
|
NDC 54458111
|
| Hospital Charge Code |
25001277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| 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 |
$13.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.92
|
| 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
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
PUSHLOCK 2.9*15.5 AR-1923BC
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
PUSHLOCK 3.5MM*19.5MM
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
PUSHLOCK 3.5MM*19.5MM
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
PUSHLOCK 3.5 SELF PUNCH
|
Facility
|
OP
|
$3,771.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,131.56 |
| Max. Negotiated Rate |
$3,621.00 |
| Rate for Payer: Aetna Commercial |
$2,904.35
|
| Rate for Payer: Anthem Medicaid |
$1,297.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,942.07
|
| Rate for Payer: Cash Price |
$1,885.94
|
| Rate for Payer: Cigna Commercial |
$3,130.66
|
| Rate for Payer: First Health Commercial |
$3,583.29
|
| Rate for Payer: Humana Commercial |
$3,206.10
|
| Rate for Payer: Humana KY Medicaid |
$1,297.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1,310.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,092.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,783.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,131.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,323.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,319.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,828.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,281.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,602.60
|
| Rate for Payer: PHCS Commercial |
$3,621.00
|
| Rate for Payer: United Healthcare All Payer |
$3,319.25
|
|
|
PUSHLOCK 3.5 SELF PUNCH
|
Facility
|
IP
|
$3,771.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,131.56 |
| Max. Negotiated Rate |
$3,621.00 |
| Rate for Payer: Aetna Commercial |
$2,904.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,942.07
|
| Rate for Payer: Cash Price |
$1,885.94
|
| Rate for Payer: Cigna Commercial |
$3,130.66
|
| Rate for Payer: First Health Commercial |
$3,583.29
|
| Rate for Payer: Humana Commercial |
$3,206.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,092.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,783.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,131.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,319.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,828.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,281.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,602.60
|
| Rate for Payer: PHCS Commercial |
$3,621.00
|
| Rate for Payer: United Healthcare All Payer |
$3,319.25
|
|
|
PUSHLOCK DISP KT F/2.9 AR-1923
|
Facility
|
OP
|
$1,998.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.48 |
| Max. Negotiated Rate |
$1,918.32 |
| Rate for Payer: Aetna Commercial |
$1,538.65
|
| Rate for Payer: Anthem Medicaid |
$687.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,558.63
|
| Rate for Payer: Cash Price |
$999.12
|
| Rate for Payer: Cigna Commercial |
$1,658.55
|
| Rate for Payer: First Health Commercial |
$1,898.34
|
| Rate for Payer: Humana Commercial |
$1,698.51
|
| Rate for Payer: Humana KY Medicaid |
$687.20
|
| Rate for Payer: Kentucky WC Medicaid |
$694.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,638.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,474.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$700.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,758.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,498.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,598.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,738.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,378.79
|
| Rate for Payer: PHCS Commercial |
$1,918.32
|
| Rate for Payer: United Healthcare All Payer |
$1,758.46
|
|
|
PUSHLOCK DISP KT F/2.9 AR-1923
|
Facility
|
IP
|
$1,998.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.48 |
| Max. Negotiated Rate |
$1,918.32 |
| Rate for Payer: Aetna Commercial |
$1,538.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,558.63
|
| Rate for Payer: Cash Price |
$999.12
|
| Rate for Payer: Cigna Commercial |
$1,658.55
|
| Rate for Payer: First Health Commercial |
$1,898.34
|
| Rate for Payer: Humana Commercial |
$1,698.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,638.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,474.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,758.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,498.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,598.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,738.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,378.79
|
| Rate for Payer: PHCS Commercial |
$1,918.32
|
| Rate for Payer: United Healthcare All Payer |
$1,758.46
|
|
