|
BRST IMP MEMORYGEL MOD+ 375CC
|
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+ 400CC
|
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+ 400CC
|
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+ 425CC
|
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+ 425CC
|
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+ 475CC
|
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+ 475CC
|
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+ 500CC
|
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+ 500CC
|
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+ 525CC
|
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+ 525CC
|
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+ 550CC
|
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+ 550CC
|
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+ 575CC
|
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+ 575CC
|
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+ 600CC
|
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+ 600CC
|
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+ 650CC
|
Facility
|
IP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
|
BRST IMP MEMORYGEL MOD+ 650CC
|
Facility
|
OP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem Medicaid |
$6,571.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Humana KY Medicaid |
$6,571.07
|
| Rate for Payer: Kentucky WC Medicaid |
$6,637.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,702.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
|
BRST IMP MEMORYGEL MOD+ 700CC
|
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+ 700CC
|
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+ 750CC
|
Facility
|
OP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem Medicaid |
$6,571.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Humana KY Medicaid |
$6,571.07
|
| Rate for Payer: Kentucky WC Medicaid |
$6,637.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,702.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
|
BRST IMP MEMORYGEL MOD+ 750CC
|
Facility
|
IP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
|
BRST IMP MEMORYGEL MOD+ 800CC
|
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+ 800CC
|
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
|
|
