|
MATERNITY ROOM RATE
|
Facility
|
IP
|
$3,512.00
|
|
| Hospital Charge Code |
11000005
|
|
Hospital Revenue Code
|
110
|
| Min. Negotiated Rate |
$1,053.60 |
| Max. Negotiated Rate |
$3,371.52 |
| Rate for Payer: Aetna Commercial |
$2,704.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.36
|
| Rate for Payer: Cash Price |
$1,756.00
|
| Rate for Payer: Cigna Commercial |
$2,914.96
|
| Rate for Payer: First Health Commercial |
$3,336.40
|
| Rate for Payer: Humana Commercial |
$2,985.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,879.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,591.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,090.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,809.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,055.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.28
|
| Rate for Payer: PHCS Commercial |
$3,371.52
|
| Rate for Payer: United Healthcare All Payer |
$3,090.56
|
|
|
MATRISTEM MATRIX 10CM*15CM
|
Facility
|
OP
|
$16,055.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem Medicaid |
$5,521.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Humana KY Medicaid |
$5,521.31
|
| Rate for Payer: Kentucky WC Medicaid |
$5,577.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,632.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
MATRISTEM MATRIX 10CM*15CM
|
Facility
|
IP
|
$16,055.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
MATRISTEM MATRIX 4CM*12CM
|
Facility
|
OP
|
$6,679.20
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,003.76 |
| Max. Negotiated Rate |
$6,412.03 |
| Rate for Payer: Aetna Commercial |
$5,142.98
|
| Rate for Payer: Anthem Medicaid |
$2,296.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,209.78
|
| Rate for Payer: Cash Price |
$3,339.60
|
| Rate for Payer: Cigna Commercial |
$5,543.74
|
| Rate for Payer: First Health Commercial |
$6,345.24
|
| Rate for Payer: Humana Commercial |
$5,677.32
|
| Rate for Payer: Humana KY Medicaid |
$2,296.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,320.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,476.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,929.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,343.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,877.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,009.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,343.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,810.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,608.65
|
| Rate for Payer: PHCS Commercial |
$6,412.03
|
| Rate for Payer: United Healthcare All Payer |
$5,877.70
|
|
|
MATRISTEM MATRIX 4CM*12CM
|
Facility
|
IP
|
$6,679.20
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,003.76 |
| Max. Negotiated Rate |
$6,412.03 |
| Rate for Payer: Aetna Commercial |
$5,142.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,209.78
|
| Rate for Payer: Cash Price |
$3,339.60
|
| Rate for Payer: Cigna Commercial |
$5,543.74
|
| Rate for Payer: First Health Commercial |
$6,345.24
|
| Rate for Payer: Humana Commercial |
$5,677.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,476.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,929.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,877.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,009.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,343.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,810.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,608.65
|
| Rate for Payer: PHCS Commercial |
$6,412.03
|
| Rate for Payer: United Healthcare All Payer |
$5,877.70
|
|
|
MATRISTEM MATRIX 5CM*5CM
|
Facility
|
IP
|
$3,968.75
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,190.62 |
| Max. Negotiated Rate |
$3,810.00 |
| Rate for Payer: Aetna Commercial |
$3,055.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.62
|
| Rate for Payer: Cash Price |
$1,984.38
|
| Rate for Payer: Cigna Commercial |
$3,294.06
|
| Rate for Payer: First Health Commercial |
$3,770.31
|
| Rate for Payer: Humana Commercial |
$3,373.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,928.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,452.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.44
|
| Rate for Payer: PHCS Commercial |
$3,810.00
|
| Rate for Payer: United Healthcare All Payer |
$3,492.50
|
|
|
MATRISTEM MATRIX 5CM*5CM
|
Facility
|
OP
|
$3,968.75
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,190.62 |
| Max. Negotiated Rate |
$3,810.00 |
| Rate for Payer: Aetna Commercial |
$3,055.94
|
| Rate for Payer: Anthem Medicaid |
$1,364.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.62
|
| Rate for Payer: Cash Price |
$1,984.38
|
| Rate for Payer: Cigna Commercial |
$3,294.06
|
| Rate for Payer: First Health Commercial |
$3,770.31
|
| Rate for Payer: Humana Commercial |
$3,373.44
|
| Rate for Payer: Humana KY Medicaid |
$1,364.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,928.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,452.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.44
|
| Rate for Payer: PHCS Commercial |
$3,810.00
|
| Rate for Payer: United Healthcare All Payer |
$3,492.50
|
|
|
MATRISTEM MATRIX 6CM*15CM
|
Facility
|
IP
|
$9,898.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,969.55 |
| Max. Negotiated Rate |
$9,502.56 |
| Rate for Payer: Aetna Commercial |
$7,621.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,720.83
|
| Rate for Payer: Cash Price |
$4,949.25
|
| Rate for Payer: Cigna Commercial |
$8,215.75
|
| Rate for Payer: First Health Commercial |
$9,403.58
|
| Rate for Payer: Humana Commercial |
$8,413.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,116.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,305.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,969.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,710.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,423.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,918.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,611.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,829.97
|
| Rate for Payer: PHCS Commercial |
$9,502.56
|
| Rate for Payer: United Healthcare All Payer |
$8,710.68
|
|
|
MATRISTEM MATRIX 6CM*15CM
|
Facility
|
OP
|
$9,898.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,969.55 |
| Max. Negotiated Rate |
$9,502.56 |
| Rate for Payer: Aetna Commercial |
$7,621.85
|
| Rate for Payer: Anthem Medicaid |
$3,404.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,720.83
|
| Rate for Payer: Cash Price |
$4,949.25
|
| Rate for Payer: Cigna Commercial |
$8,215.75
|
| Rate for Payer: First Health Commercial |
$9,403.58
|
| Rate for Payer: Humana Commercial |
$8,413.73
|
| Rate for Payer: Humana KY Medicaid |
$3,404.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,438.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,116.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,305.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,969.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,472.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,710.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,423.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,918.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,611.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,829.97
|
| Rate for Payer: PHCS Commercial |
$9,502.56
|
| Rate for Payer: United Healthcare All Payer |
$8,710.68
|
|
|
MATRISTEM MATRIX 7CM*10CM
|
Facility
|
IP
|
$8,365.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,509.65 |
| Max. Negotiated Rate |
$8,030.88 |
| Rate for Payer: Aetna Commercial |
$6,441.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,525.09
|
| Rate for Payer: Cash Price |
$4,182.75
|
| Rate for Payer: Cigna Commercial |
$6,943.36
|
| Rate for Payer: First Health Commercial |
$7,947.23
|
| Rate for Payer: Humana Commercial |
$7,110.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,859.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,173.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,509.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,361.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,274.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,692.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,277.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,772.19
|
| Rate for Payer: PHCS Commercial |
$8,030.88
|
| Rate for Payer: United Healthcare All Payer |
$7,361.64
|
|
|
MATRISTEM MATRIX 7CM*10CM
|
Facility
|
OP
|
$8,365.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,509.65 |
| Max. Negotiated Rate |
$8,030.88 |
| Rate for Payer: Aetna Commercial |
$6,441.44
|
| Rate for Payer: Anthem Medicaid |
$2,876.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,525.09
|
| Rate for Payer: Cash Price |
$4,182.75
|
| Rate for Payer: Cigna Commercial |
$6,943.36
|
| Rate for Payer: First Health Commercial |
$7,947.23
|
| Rate for Payer: Humana Commercial |
$7,110.68
|
| Rate for Payer: Humana KY Medicaid |
$2,876.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,906.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,859.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,173.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,509.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,934.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,361.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,274.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,692.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,277.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,772.19
|
| Rate for Payer: PHCS Commercial |
$8,030.88
|
| Rate for Payer: United Healthcare All Payer |
$7,361.64
|
|
|
MATRISTEM MATRIX 7CM*15CM
|
Facility
|
OP
|
$9,898.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,969.55 |
| Max. Negotiated Rate |
$9,502.56 |
| Rate for Payer: Aetna Commercial |
$7,621.85
|
| Rate for Payer: Anthem Medicaid |
$3,404.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,720.83
|
| Rate for Payer: Cash Price |
$4,949.25
|
| Rate for Payer: Cigna Commercial |
$8,215.75
|
| Rate for Payer: First Health Commercial |
$9,403.58
|
| Rate for Payer: Humana Commercial |
$8,413.73
|
| Rate for Payer: Humana KY Medicaid |
$3,404.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,438.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,116.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,305.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,969.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,472.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,710.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,423.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,918.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,611.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,829.97
|
| Rate for Payer: PHCS Commercial |
$9,502.56
|
| Rate for Payer: United Healthcare All Payer |
$8,710.68
|
|
|
MATRISTEM MATRIX 7CM*15CM
|
Facility
|
IP
|
$9,898.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,969.55 |
| Max. Negotiated Rate |
$9,502.56 |
| Rate for Payer: Aetna Commercial |
$7,621.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,720.83
|
| Rate for Payer: Cash Price |
$4,949.25
|
| Rate for Payer: Cigna Commercial |
$8,215.75
|
| Rate for Payer: First Health Commercial |
$9,403.58
|
| Rate for Payer: Humana Commercial |
$8,413.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,116.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,305.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,969.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,710.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,423.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,918.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,611.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,829.97
|
| Rate for Payer: PHCS Commercial |
$9,502.56
|
| Rate for Payer: United Healthcare All Payer |
$8,710.68
|
|
|
MATRISTEM MATRIX XS 10CM*15CM
|
Facility
|
OP
|
$21,875.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem Medicaid |
$7,522.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Humana KY Medicaid |
$7,522.81
|
| Rate for Payer: Kentucky WC Medicaid |
$7,599.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,673.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
MATRISTEM MATRIX XS 10CM*15CM
|
Facility
|
IP
|
$21,875.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
MATRISTEM MATRIX XS 4CM*12CM
|
Facility
|
IP
|
$8,256.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,476.80 |
| Max. Negotiated Rate |
$7,925.76 |
| Rate for Payer: Aetna Commercial |
$6,357.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,439.68
|
| Rate for Payer: Cash Price |
$4,128.00
|
| Rate for Payer: Cigna Commercial |
$6,852.48
|
| Rate for Payer: First Health Commercial |
$7,843.20
|
| Rate for Payer: Humana Commercial |
$7,017.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,769.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,092.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,476.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,182.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,696.64
|
| Rate for Payer: PHCS Commercial |
$7,925.76
|
| Rate for Payer: United Healthcare All Payer |
$7,265.28
|
|
|
MATRISTEM MATRIX XS 4CM*12CM
|
Facility
|
OP
|
$8,256.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,476.80 |
| Max. Negotiated Rate |
$7,925.76 |
| Rate for Payer: Aetna Commercial |
$6,357.12
|
| Rate for Payer: Anthem Medicaid |
$2,839.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,439.68
|
| Rate for Payer: Cash Price |
$4,128.00
|
| Rate for Payer: Cigna Commercial |
$6,852.48
|
| Rate for Payer: First Health Commercial |
$7,843.20
|
| Rate for Payer: Humana Commercial |
$7,017.60
|
| Rate for Payer: Humana KY Medicaid |
$2,839.24
|
| Rate for Payer: Kentucky WC Medicaid |
$2,868.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,769.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,092.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,476.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,896.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,182.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,696.64
|
| Rate for Payer: PHCS Commercial |
$7,925.76
|
| Rate for Payer: United Healthcare All Payer |
$7,265.28
|
|
|
MATRISTEM MATRIX XS 5CM*5CM
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
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
|
|
|
MATRISTEM MATRIX XS 5CM*5CM
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
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
|
|
|
MATRISTEM MATRIX XS 6CM*15CM
|
Facility
|
IP
|
$13,409.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,022.70 |
| Max. Negotiated Rate |
$12,872.64 |
| Rate for Payer: Aetna Commercial |
$10,324.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,459.02
|
| Rate for Payer: Cash Price |
$6,704.50
|
| Rate for Payer: Cigna Commercial |
$11,129.47
|
| Rate for Payer: First Health Commercial |
$12,738.55
|
| Rate for Payer: Humana Commercial |
$11,397.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,995.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,895.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,022.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,799.92
|
| Rate for Payer: Ohio Health Group HMO |
$10,056.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,665.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,252.21
|
| Rate for Payer: PHCS Commercial |
$12,872.64
|
| Rate for Payer: United Healthcare All Payer |
$11,799.92
|
|
|
MATRISTEM MATRIX XS 6CM*15CM
|
Facility
|
OP
|
$13,409.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,022.70 |
| Max. Negotiated Rate |
$12,872.64 |
| Rate for Payer: Aetna Commercial |
$10,324.93
|
| Rate for Payer: Anthem Medicaid |
$4,611.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,459.02
|
| Rate for Payer: Cash Price |
$6,704.50
|
| Rate for Payer: Cigna Commercial |
$11,129.47
|
| Rate for Payer: First Health Commercial |
$12,738.55
|
| Rate for Payer: Humana Commercial |
$11,397.65
|
| Rate for Payer: Humana KY Medicaid |
$4,611.36
|
| Rate for Payer: Kentucky WC Medicaid |
$4,658.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,995.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,895.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,022.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,703.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,799.92
|
| Rate for Payer: Ohio Health Group HMO |
$10,056.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,665.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,252.21
|
| Rate for Payer: PHCS Commercial |
$12,872.64
|
| Rate for Payer: United Healthcare All Payer |
$11,799.92
|
|
|
MATRISTEM MATRIX XS 7CM*10CM
|
Facility
|
OP
|
$11,207.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem Medicaid |
$3,854.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Humana KY Medicaid |
$3,854.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,893.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,931.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
MATRISTEM MATRIX XS 7CM*10CM
|
Facility
|
IP
|
$11,207.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
MATRISTEM MATRIX XS 8CM*16CM
|
Facility
|
IP
|
$18,608.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,582.40 |
| Max. Negotiated Rate |
$17,863.68 |
| Rate for Payer: Aetna Commercial |
$14,328.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,514.24
|
| Rate for Payer: Cash Price |
$9,304.00
|
| Rate for Payer: Cigna Commercial |
$15,444.64
|
| Rate for Payer: First Health Commercial |
$17,677.60
|
| Rate for Payer: Humana Commercial |
$15,816.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,258.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,732.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,582.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,375.04
|
| Rate for Payer: Ohio Health Group HMO |
$13,956.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,886.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,188.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,839.52
|
| Rate for Payer: PHCS Commercial |
$17,863.68
|
| Rate for Payer: United Healthcare All Payer |
$16,375.04
|
|
|
MATRISTEM MATRIX XS 8CM*16CM
|
Facility
|
OP
|
$18,608.00
|
|
|
Service Code
|
HCPCS Q4118
|
| Hospital Charge Code |
27000120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,582.40 |
| Max. Negotiated Rate |
$17,863.68 |
| Rate for Payer: Aetna Commercial |
$14,328.16
|
| Rate for Payer: Anthem Medicaid |
$6,399.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,514.24
|
| Rate for Payer: Cash Price |
$9,304.00
|
| Rate for Payer: Cigna Commercial |
$15,444.64
|
| Rate for Payer: First Health Commercial |
$17,677.60
|
| Rate for Payer: Humana Commercial |
$15,816.80
|
| Rate for Payer: Humana KY Medicaid |
$6,399.29
|
| Rate for Payer: Kentucky WC Medicaid |
$6,464.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,258.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,732.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,582.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,527.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,375.04
|
| Rate for Payer: Ohio Health Group HMO |
$13,956.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,886.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,188.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,839.52
|
| Rate for Payer: PHCS Commercial |
$17,863.68
|
| Rate for Payer: United Healthcare All Payer |
$16,375.04
|
|
