|
AMNIO ALLOGFT PLACEN MATRI 2*2
|
Facility
|
OP
|
$5,623.88
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.10 |
| Max. Negotiated Rate |
$5,398.92 |
| Rate for Payer: Aetna Commercial |
$4,330.39
|
| Rate for Payer: Anthem Medicaid |
$1,934.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,386.63
|
| Rate for Payer: Cash Price |
$2,811.94
|
| Rate for Payer: Cigna Commercial |
$4,667.82
|
| Rate for Payer: First Health Commercial |
$5,342.69
|
| Rate for Payer: Humana Commercial |
$4,780.30
|
| Rate for Payer: Humana KY Medicaid |
$1,934.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,953.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,611.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,150.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,687.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,972.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,949.01
|
| Rate for Payer: Ohio Health Group HMO |
$4,217.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,124.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$731.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,743.40
|
| Rate for Payer: PHCS Commercial |
$5,398.92
|
| Rate for Payer: United Healthcare All Payer |
$4,949.01
|
|
|
AMNIO ALLOGFT PLACEN MATRI 4*4
|
Facility
|
IP
|
$15,010.80
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,951.40 |
| Max. Negotiated Rate |
$14,410.37 |
| Rate for Payer: Aetna Commercial |
$11,558.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,708.42
|
| Rate for Payer: Cash Price |
$7,505.40
|
| Rate for Payer: Cigna Commercial |
$12,458.96
|
| Rate for Payer: First Health Commercial |
$14,260.26
|
| Rate for Payer: Humana Commercial |
$12,759.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,308.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,077.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,503.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,209.50
|
| Rate for Payer: Ohio Health Group HMO |
$11,258.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,002.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,951.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,653.35
|
| Rate for Payer: PHCS Commercial |
$14,410.37
|
| Rate for Payer: United Healthcare All Payer |
$13,209.50
|
|
|
AMNIO ALLOGFT PLACEN MATRI 4*4
|
Facility
|
OP
|
$15,010.80
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,951.40 |
| Max. Negotiated Rate |
$14,410.37 |
| Rate for Payer: Aetna Commercial |
$11,558.32
|
| Rate for Payer: Anthem Medicaid |
$5,162.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,708.42
|
| Rate for Payer: Cash Price |
$7,505.40
|
| Rate for Payer: Cigna Commercial |
$12,458.96
|
| Rate for Payer: First Health Commercial |
$14,260.26
|
| Rate for Payer: Humana Commercial |
$12,759.18
|
| Rate for Payer: Humana KY Medicaid |
$5,162.21
|
| Rate for Payer: Kentucky WC Medicaid |
$5,214.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,308.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,077.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,503.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,265.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,209.50
|
| Rate for Payer: Ohio Health Group HMO |
$11,258.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,002.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,951.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,653.35
|
| Rate for Payer: PHCS Commercial |
$14,410.37
|
| Rate for Payer: United Healthcare All Payer |
$13,209.50
|
|
|
AMNIO ALLOGFT PLACEN MATRI 5*6
|
Facility
|
IP
|
$25,393.30
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,301.13 |
| Max. Negotiated Rate |
$24,377.57 |
| Rate for Payer: Aetna Commercial |
$19,552.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,806.77
|
| Rate for Payer: Cash Price |
$12,696.65
|
| Rate for Payer: Cigna Commercial |
$21,076.44
|
| Rate for Payer: First Health Commercial |
$24,123.64
|
| Rate for Payer: Humana Commercial |
$21,584.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,822.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,740.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,617.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,346.10
|
| Rate for Payer: Ohio Health Group HMO |
$19,044.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,078.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,301.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,871.92
|
| Rate for Payer: PHCS Commercial |
$24,377.57
|
| Rate for Payer: United Healthcare All Payer |
$22,346.10
|
|
|
AMNIO ALLOGFT PLACEN MATRI 5*6
|
Facility
|
OP
|
$25,393.30
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,301.13 |
| Max. Negotiated Rate |
$24,377.57 |
| Rate for Payer: Aetna Commercial |
$19,552.84
|
| Rate for Payer: Anthem Medicaid |
$8,732.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,806.77
|
| Rate for Payer: Cash Price |
$12,696.65
|
| Rate for Payer: Cigna Commercial |
$21,076.44
|
| Rate for Payer: First Health Commercial |
$24,123.64
|
| Rate for Payer: Humana Commercial |
$21,584.30
|
| Rate for Payer: Humana KY Medicaid |
$8,732.76
|
| Rate for Payer: Kentucky WC Medicaid |
$8,821.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,822.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,740.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,617.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,907.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,346.10
|
| Rate for Payer: Ohio Health Group HMO |
$19,044.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,078.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,301.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,871.92
|
| Rate for Payer: PHCS Commercial |
$24,377.57
|
| Rate for Payer: United Healthcare All Payer |
$22,346.10
|
|
|
AMNIO ALLOGFT PLACEN MATRI 7*7
|
Facility
|
IP
|
$38,015.00
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,941.95 |
| Max. Negotiated Rate |
$36,494.40 |
| Rate for Payer: Aetna Commercial |
$29,271.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,651.70
|
| Rate for Payer: Cash Price |
$19,007.50
|
| Rate for Payer: Cigna Commercial |
$31,552.45
|
| Rate for Payer: First Health Commercial |
$36,114.25
|
| Rate for Payer: Humana Commercial |
$32,312.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,172.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,055.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,404.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,453.20
|
| Rate for Payer: Ohio Health Group HMO |
$28,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,603.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,941.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,784.65
|
| Rate for Payer: PHCS Commercial |
$36,494.40
|
| Rate for Payer: United Healthcare All Payer |
$33,453.20
|
|
|
AMNIO ALLOGFT PLACEN MATRI 7*7
|
Facility
|
OP
|
$38,015.00
|
|
|
Service Code
|
HCPCS Q4151
|
| Hospital Charge Code |
27000287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,941.95 |
| Max. Negotiated Rate |
$36,494.40 |
| Rate for Payer: Aetna Commercial |
$29,271.55
|
| Rate for Payer: Anthem Medicaid |
$13,073.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,651.70
|
| Rate for Payer: Cash Price |
$19,007.50
|
| Rate for Payer: Cigna Commercial |
$31,552.45
|
| Rate for Payer: First Health Commercial |
$36,114.25
|
| Rate for Payer: Humana Commercial |
$32,312.75
|
| Rate for Payer: Humana KY Medicaid |
$13,073.36
|
| Rate for Payer: Kentucky WC Medicaid |
$13,206.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,172.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,055.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,404.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,335.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,453.20
|
| Rate for Payer: Ohio Health Group HMO |
$28,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,603.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,941.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,784.65
|
| Rate for Payer: PHCS Commercial |
$36,494.40
|
| Rate for Payer: United Healthcare All Payer |
$33,453.20
|
|
|
AMNIOCENTESIS
|
Facility
|
IP
|
$948.00
|
|
|
Service Code
|
HCPCS 59000
|
| Hospital Charge Code |
76102268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.24 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.88
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
AMNIOCENTESIS
|
Facility
|
OP
|
$948.00
|
|
|
Service Code
|
HCPCS 59000
|
| Hospital Charge Code |
76102268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.24 |
| Max. Negotiated Rate |
$973.27 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem Medicaid |
$326.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$695.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$973.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$938.51
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Humana KY Medicaid |
$326.02
|
| Rate for Payer: Humana Medicare Advantage |
$695.19
|
| Rate for Payer: Kentucky WC Medicaid |
$329.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$834.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.88
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
AMNIOCORD 3X5 CM
|
Facility
|
IP
|
$9,351.75
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27000115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,215.73 |
| Max. Negotiated Rate |
$8,977.68 |
| Rate for Payer: Aetna Commercial |
$7,200.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,294.36
|
| Rate for Payer: Cash Price |
$4,675.88
|
| Rate for Payer: Cigna Commercial |
$7,761.95
|
| Rate for Payer: First Health Commercial |
$8,884.16
|
| Rate for Payer: Humana Commercial |
$7,948.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,668.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,901.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,229.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,013.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,870.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,215.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,899.04
|
| Rate for Payer: PHCS Commercial |
$8,977.68
|
| Rate for Payer: United Healthcare All Payer |
$8,229.54
|
|
|
AMNIOCORD 3X5 CM
|
Facility
|
OP
|
$9,351.75
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27000115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,215.73 |
| Max. Negotiated Rate |
$8,977.68 |
| Rate for Payer: Aetna Commercial |
$7,200.85
|
| Rate for Payer: Anthem Medicaid |
$3,216.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,294.36
|
| Rate for Payer: Cash Price |
$4,675.88
|
| Rate for Payer: Cigna Commercial |
$7,761.95
|
| Rate for Payer: First Health Commercial |
$8,884.16
|
| Rate for Payer: Humana Commercial |
$7,948.99
|
| Rate for Payer: Humana KY Medicaid |
$3,216.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,248.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,668.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,901.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,805.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,280.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,229.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,013.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,870.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,215.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,899.04
|
| Rate for Payer: PHCS Commercial |
$8,977.68
|
| Rate for Payer: United Healthcare All Payer |
$8,229.54
|
|
|
AMNIOEXCEL BIODEXCEL 1SQ CM
|
Facility
|
IP
|
$1,424.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.12 |
| Max. Negotiated Rate |
$1,367.04 |
| Rate for Payer: Aetna Commercial |
$1,096.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,110.72
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$1,181.92
|
| Rate for Payer: First Health Commercial |
$1,352.80
|
| Rate for Payer: Humana Commercial |
$1,210.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,167.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,050.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,253.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$185.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.44
|
| Rate for Payer: PHCS Commercial |
$1,367.04
|
| Rate for Payer: United Healthcare All Payer |
$1,253.12
|
|
|
AMNIOEXCEL BIODEXCEL 1SQ CM
|
Facility
|
OP
|
$1,424.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.12 |
| Max. Negotiated Rate |
$1,367.04 |
| Rate for Payer: Aetna Commercial |
$1,096.48
|
| Rate for Payer: Anthem Medicaid |
$489.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,110.72
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$1,181.92
|
| Rate for Payer: First Health Commercial |
$1,352.80
|
| Rate for Payer: Humana Commercial |
$1,210.40
|
| Rate for Payer: Humana KY Medicaid |
$489.71
|
| Rate for Payer: Kentucky WC Medicaid |
$494.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,167.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,050.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$499.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,253.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$185.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.44
|
| Rate for Payer: PHCS Commercial |
$1,367.04
|
| Rate for Payer: United Healthcare All Payer |
$1,253.12
|
|
|
AMNIOEXCEL PLUS 2CM*2CM
|
Facility
|
IP
|
$6,578.30
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$855.18 |
| Max. Negotiated Rate |
$6,315.17 |
| Rate for Payer: Aetna Commercial |
$5,065.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,131.07
|
| Rate for Payer: Cash Price |
$3,289.15
|
| Rate for Payer: Cigna Commercial |
$5,459.99
|
| Rate for Payer: First Health Commercial |
$6,249.38
|
| Rate for Payer: Humana Commercial |
$5,591.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,394.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,854.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,973.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,788.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,933.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,315.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$855.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,039.27
|
| Rate for Payer: PHCS Commercial |
$6,315.17
|
| Rate for Payer: United Healthcare All Payer |
$5,788.90
|
|
|
AMNIOEXCEL PLUS 2CM*2CM
|
Facility
|
OP
|
$6,578.30
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$855.18 |
| Max. Negotiated Rate |
$6,315.17 |
| Rate for Payer: Aetna Commercial |
$5,065.29
|
| Rate for Payer: Anthem Medicaid |
$2,262.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,131.07
|
| Rate for Payer: Cash Price |
$3,289.15
|
| Rate for Payer: Cigna Commercial |
$5,459.99
|
| Rate for Payer: First Health Commercial |
$6,249.38
|
| Rate for Payer: Humana Commercial |
$5,591.56
|
| Rate for Payer: Humana KY Medicaid |
$2,262.28
|
| Rate for Payer: Kentucky WC Medicaid |
$2,285.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,394.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,854.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,973.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,307.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,788.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,933.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,315.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$855.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,039.27
|
| Rate for Payer: PHCS Commercial |
$6,315.17
|
| Rate for Payer: United Healthcare All Payer |
$5,788.90
|
|
|
AMNIOEXCEL PLUS 3CM*4CM
|
Facility
|
IP
|
$11,044.57
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,435.79 |
| Max. Negotiated Rate |
$10,602.79 |
| Rate for Payer: Aetna Commercial |
$8,504.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,614.76
|
| Rate for Payer: Cash Price |
$5,522.28
|
| Rate for Payer: Cigna Commercial |
$9,166.99
|
| Rate for Payer: First Health Commercial |
$10,492.34
|
| Rate for Payer: Humana Commercial |
$9,387.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,056.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,150.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,313.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,719.22
|
| Rate for Payer: Ohio Health Group HMO |
$8,283.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,208.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,435.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,423.82
|
| Rate for Payer: PHCS Commercial |
$10,602.79
|
| Rate for Payer: United Healthcare All Payer |
$9,719.22
|
|
|
AMNIOEXCEL PLUS 3CM*4CM
|
Facility
|
OP
|
$11,044.57
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,435.79 |
| Max. Negotiated Rate |
$10,602.79 |
| Rate for Payer: Aetna Commercial |
$8,504.32
|
| Rate for Payer: Anthem Medicaid |
$3,798.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,614.76
|
| Rate for Payer: Cash Price |
$5,522.28
|
| Rate for Payer: Cigna Commercial |
$9,166.99
|
| Rate for Payer: First Health Commercial |
$10,492.34
|
| Rate for Payer: Humana Commercial |
$9,387.88
|
| Rate for Payer: Humana KY Medicaid |
$3,798.23
|
| Rate for Payer: Kentucky WC Medicaid |
$3,836.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,056.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,150.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,313.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,874.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,719.22
|
| Rate for Payer: Ohio Health Group HMO |
$8,283.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,208.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,435.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,423.82
|
| Rate for Payer: PHCS Commercial |
$10,602.79
|
| Rate for Payer: United Healthcare All Payer |
$9,719.22
|
|
|
AMNIOFILL 250 MG
|
Facility
|
IP
|
$4,037.50
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.88 |
| Max. Negotiated Rate |
$3,876.00 |
| Rate for Payer: Aetna Commercial |
$3,108.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,149.25
|
| Rate for Payer: Cash Price |
$2,018.75
|
| Rate for Payer: Cigna Commercial |
$3,351.12
|
| Rate for Payer: First Health Commercial |
$3,835.62
|
| Rate for Payer: Humana Commercial |
$3,431.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,310.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,979.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,211.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,553.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,028.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$807.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$524.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,251.62
|
| Rate for Payer: PHCS Commercial |
$3,876.00
|
| Rate for Payer: United Healthcare All Payer |
$3,553.00
|
|
|
AMNIOFILL 250 MG
|
Facility
|
OP
|
$4,037.50
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.88 |
| Max. Negotiated Rate |
$3,876.00 |
| Rate for Payer: Aetna Commercial |
$3,108.88
|
| Rate for Payer: Anthem Medicaid |
$1,388.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,149.25
|
| Rate for Payer: Cash Price |
$2,018.75
|
| Rate for Payer: Cigna Commercial |
$3,351.12
|
| Rate for Payer: First Health Commercial |
$3,835.62
|
| Rate for Payer: Humana Commercial |
$3,431.88
|
| Rate for Payer: Humana KY Medicaid |
$1,388.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,402.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,310.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,979.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,211.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,416.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,553.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,028.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$807.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$524.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,251.62
|
| Rate for Payer: PHCS Commercial |
$3,876.00
|
| Rate for Payer: United Healthcare All Payer |
$3,553.00
|
|
|
AMNIOFILL 500MG
|
Facility
|
IP
|
$21,225.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,759.25 |
| Max. Negotiated Rate |
$20,376.00 |
| Rate for Payer: Aetna Commercial |
$16,343.25
|
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,555.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$10,612.50
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$17,616.75
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: First Health Commercial |
$20,163.75
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Humana Commercial |
$18,041.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,404.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,664.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,678.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.75
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,245.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,759.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,579.75
|
| Rate for Payer: PHCS Commercial |
$20,376.00
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$18,678.00
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
AMNIOFILL 500MG
|
Facility
|
OP
|
$21,225.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,759.25 |
| Max. Negotiated Rate |
$20,376.00 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,555.50
|
| Rate for Payer: Aetna Commercial |
$16,343.25
|
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem Medicaid |
$7,299.28
|
| Rate for Payer: Anthem Medicaid |
$2,280.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$10,612.50
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: Cigna Commercial |
$17,616.75
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: First Health Commercial |
$20,163.75
|
| Rate for Payer: Humana Commercial |
$18,041.25
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Humana KY Medicaid |
$7,299.28
|
| Rate for Payer: Humana KY Medicaid |
$2,280.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,304.13
|
| Rate for Payer: Kentucky WC Medicaid |
$7,373.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,404.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,664.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,445.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,326.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,678.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.75
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,245.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,759.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,579.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: PHCS Commercial |
$20,376.00
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
| Rate for Payer: United Healthcare All Payer |
$18,678.00
|
|
|
AMNIOFIX 7CM*6CM
|
Facility
|
OP
|
$10,078.10
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,310.15 |
| Max. Negotiated Rate |
$9,674.98 |
| Rate for Payer: Aetna Commercial |
$7,760.14
|
| Rate for Payer: Anthem Medicaid |
$3,465.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,860.92
|
| Rate for Payer: Cash Price |
$5,039.05
|
| Rate for Payer: Cigna Commercial |
$8,364.82
|
| Rate for Payer: First Health Commercial |
$9,574.20
|
| Rate for Payer: Humana Commercial |
$8,566.38
|
| Rate for Payer: Humana KY Medicaid |
$3,465.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,501.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,264.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,437.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,023.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,535.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,868.73
|
| Rate for Payer: Ohio Health Group HMO |
$7,558.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,015.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,124.21
|
| Rate for Payer: PHCS Commercial |
$9,674.98
|
| Rate for Payer: United Healthcare All Payer |
$8,868.73
|
|
|
AMNIOFIX 7CM*6CM
|
Facility
|
IP
|
$10,078.10
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,310.15 |
| Max. Negotiated Rate |
$9,674.98 |
| Rate for Payer: Aetna Commercial |
$7,760.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,860.92
|
| Rate for Payer: Cash Price |
$5,039.05
|
| Rate for Payer: Cigna Commercial |
$8,364.82
|
| Rate for Payer: First Health Commercial |
$9,574.20
|
| Rate for Payer: Humana Commercial |
$8,566.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,264.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,437.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,023.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,868.73
|
| Rate for Payer: Ohio Health Group HMO |
$7,558.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,015.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,124.21
|
| Rate for Payer: PHCS Commercial |
$9,674.98
|
| Rate for Payer: United Healthcare All Payer |
$8,868.73
|
|
|
AMNIOMATRIX ALLOGFT SUSP 1.0ML
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
AMNIOMATRIX ALLOGFT SUSP 1.0ML
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
