|
BRST IMP MEMORYGEL HIGH 650CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 650CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 700CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 700CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 750CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 750CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 800CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL HIGH 800CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP MEMORYGEL MOD+ 225CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 225CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 250CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 250CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 275CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 275CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 300CC
|
Facility
|
OP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem Medicaid |
$1,906.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Humana KY Medicaid |
$1,906.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,925.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,944.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BRST IMP MEMORYGEL MOD+ 300CC
|
Facility
|
IP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BRST IMP MEMORYGEL MOD+ 325CC
|
Facility
|
IP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BRST IMP MEMORYGEL MOD+ 325CC
|
Facility
|
OP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem Medicaid |
$1,906.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Humana KY Medicaid |
$1,906.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,925.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,944.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BRST IMP MEMORYGEL MOD+ 350CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 350CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 375CC
|
Facility
|
IP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BRST IMP MEMORYGEL MOD+ 375CC
|
Facility
|
OP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem Medicaid |
$1,906.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Humana KY Medicaid |
$1,906.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,925.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,944.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BRST IMP MEMORYGEL MOD+ 400CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 400CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP MEMORYGEL MOD+ 425CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
