|
BRST IMP MEMORYGEL HIGH 550CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 550CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 600CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 600CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 650CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 650CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 700CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 700CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 750CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 750CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 800CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL HIGH 800CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BRST IMP MEMORYGEL MOD+ 225CC
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 225CC
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 250CC
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 250CC
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 275CC
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 275CC
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 300CC
|
Facility
|
OP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem Medicaid |
$1,919.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Humana KY Medicaid |
$1,919.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,938.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,957.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
|
BRST IMP MEMORYGEL MOD+ 300CC
|
Facility
|
IP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
|
BRST IMP MEMORYGEL MOD+ 325CC
|
Facility
|
IP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
|
BRST IMP MEMORYGEL MOD+ 325CC
|
Facility
|
OP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem Medicaid |
$1,919.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Humana KY Medicaid |
$1,919.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,938.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,957.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
|
BRST IMP MEMORYGEL MOD+ 350CC
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 350CC
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BRST IMP MEMORYGEL MOD+ 375CC
|
Facility
|
OP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem Medicaid |
$1,919.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Humana KY Medicaid |
$1,919.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,938.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,957.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
