|
AMNIOCORD 3X5 CM
|
Facility
|
IP
|
$9,551.75
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27000115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,865.53 |
| Max. Negotiated Rate |
$9,169.68 |
| Rate for Payer: Aetna Commercial |
$7,354.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,450.36
|
| Rate for Payer: Cash Price |
$4,775.88
|
| Rate for Payer: Cigna Commercial |
$7,927.95
|
| Rate for Payer: First Health Commercial |
$9,074.16
|
| Rate for Payer: Humana Commercial |
$8,118.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,832.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,049.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,865.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,405.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,163.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,641.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,310.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,590.71
|
| Rate for Payer: PHCS Commercial |
$9,169.68
|
| Rate for Payer: United Healthcare All Payer |
$8,405.54
|
|
|
AMNIOCORD 3X5 CM
|
Facility
|
OP
|
$9,551.75
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27000115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,865.53 |
| Max. Negotiated Rate |
$9,169.68 |
| Rate for Payer: Aetna Commercial |
$7,354.85
|
| Rate for Payer: Anthem Medicaid |
$3,284.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,450.36
|
| Rate for Payer: Cash Price |
$4,775.88
|
| Rate for Payer: Cigna Commercial |
$7,927.95
|
| Rate for Payer: First Health Commercial |
$9,074.16
|
| Rate for Payer: Humana Commercial |
$8,118.99
|
| Rate for Payer: Humana KY Medicaid |
$3,284.85
|
| Rate for Payer: Kentucky WC Medicaid |
$3,318.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,832.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,049.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,865.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,350.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,405.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,163.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,641.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,310.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,590.71
|
| Rate for Payer: PHCS Commercial |
$9,169.68
|
| Rate for Payer: United Healthcare All Payer |
$8,405.54
|
|
|
AMNIOEXCEL BIODEXCEL 1SQ CM
|
Facility
|
OP
|
$1,424.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$427.20 |
| 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 |
$1,139.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,238.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$982.56
|
| Rate for Payer: PHCS Commercial |
$1,367.04
|
| Rate for Payer: United Healthcare All Payer |
$1,253.12
|
|
|
AMNIOEXCEL BIODEXCEL 1SQ CM
|
Facility
|
IP
|
$1,424.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$427.20 |
| 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 |
$1,139.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,238.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$982.56
|
| Rate for Payer: PHCS Commercial |
$1,367.04
|
| Rate for Payer: United Healthcare All Payer |
$1,253.12
|
|
|
AMNIOEXCEL PLUS 2CM*2CM
|
Facility
|
OP
|
$6,778.30
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,033.49 |
| Max. Negotiated Rate |
$6,507.17 |
| Rate for Payer: Aetna Commercial |
$5,219.29
|
| Rate for Payer: Anthem Medicaid |
$2,331.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,287.07
|
| Rate for Payer: Cash Price |
$3,389.15
|
| Rate for Payer: Cigna Commercial |
$5,625.99
|
| Rate for Payer: First Health Commercial |
$6,439.39
|
| Rate for Payer: Humana Commercial |
$5,761.56
|
| Rate for Payer: Humana KY Medicaid |
$2,331.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,354.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,558.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,002.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,033.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,377.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,964.90
|
| Rate for Payer: Ohio Health Group HMO |
$5,083.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,422.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,897.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,677.03
|
| Rate for Payer: PHCS Commercial |
$6,507.17
|
| Rate for Payer: United Healthcare All Payer |
$5,964.90
|
|
|
AMNIOEXCEL PLUS 2CM*2CM
|
Facility
|
IP
|
$6,778.30
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,033.49 |
| Max. Negotiated Rate |
$6,507.17 |
| Rate for Payer: Aetna Commercial |
$5,219.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,287.07
|
| Rate for Payer: Cash Price |
$3,389.15
|
| Rate for Payer: Cigna Commercial |
$5,625.99
|
| Rate for Payer: First Health Commercial |
$6,439.39
|
| Rate for Payer: Humana Commercial |
$5,761.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,558.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,002.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,033.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,964.90
|
| Rate for Payer: Ohio Health Group HMO |
$5,083.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,422.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,897.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,677.03
|
| Rate for Payer: PHCS Commercial |
$6,507.17
|
| Rate for Payer: United Healthcare All Payer |
$5,964.90
|
|
|
AMNIOEXCEL PLUS 3CM*4CM
|
Facility
|
OP
|
$11,287.01
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,386.10 |
| Max. Negotiated Rate |
$10,835.53 |
| Rate for Payer: Aetna Commercial |
$8,691.00
|
| Rate for Payer: Anthem Medicaid |
$3,881.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,803.87
|
| Rate for Payer: Cash Price |
$5,643.50
|
| Rate for Payer: Cigna Commercial |
$9,368.22
|
| Rate for Payer: First Health Commercial |
$10,722.66
|
| Rate for Payer: Humana Commercial |
$9,593.96
|
| Rate for Payer: Humana KY Medicaid |
$3,881.60
|
| Rate for Payer: Kentucky WC Medicaid |
$3,921.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,255.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,329.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,386.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,959.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,932.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,465.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,029.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,819.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,788.04
|
| Rate for Payer: PHCS Commercial |
$10,835.53
|
| Rate for Payer: United Healthcare All Payer |
$9,932.57
|
|
|
AMNIOEXCEL PLUS 3CM*4CM
|
Facility
|
IP
|
$11,287.01
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
27000245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,386.10 |
| Max. Negotiated Rate |
$10,835.53 |
| Rate for Payer: Aetna Commercial |
$8,691.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,803.87
|
| Rate for Payer: Cash Price |
$5,643.50
|
| Rate for Payer: Cigna Commercial |
$9,368.22
|
| Rate for Payer: First Health Commercial |
$10,722.66
|
| Rate for Payer: Humana Commercial |
$9,593.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,255.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,329.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,386.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,932.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,465.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,029.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,819.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,788.04
|
| Rate for Payer: PHCS Commercial |
$10,835.53
|
| Rate for Payer: United Healthcare All Payer |
$9,932.57
|
|
|
AMNIOFILL 250 MG
|
Facility
|
IP
|
$3,968.75
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,190.62 |
| Max. Negotiated Rate |
$3,810.00 |
| Rate for Payer: Aetna Commercial |
$3,055.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.62
|
| Rate for Payer: Cash Price |
$1,984.38
|
| Rate for Payer: Cigna Commercial |
$3,294.06
|
| Rate for Payer: First Health Commercial |
$3,770.31
|
| Rate for Payer: Humana Commercial |
$3,373.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,928.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,452.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.44
|
| Rate for Payer: PHCS Commercial |
$3,810.00
|
| Rate for Payer: United Healthcare All Payer |
$3,492.50
|
|
|
AMNIOFILL 250 MG
|
Facility
|
OP
|
$3,968.75
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,190.62 |
| Max. Negotiated Rate |
$3,810.00 |
| Rate for Payer: Aetna Commercial |
$3,055.94
|
| Rate for Payer: Anthem Medicaid |
$1,364.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.62
|
| Rate for Payer: Cash Price |
$1,984.38
|
| Rate for Payer: Cigna Commercial |
$3,294.06
|
| Rate for Payer: First Health Commercial |
$3,770.31
|
| Rate for Payer: Humana Commercial |
$3,373.44
|
| Rate for Payer: Humana KY Medicaid |
$1,364.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,928.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,452.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.44
|
| Rate for Payer: PHCS Commercial |
$3,810.00
|
| Rate for Payer: United Healthcare All Payer |
$3,492.50
|
|
|
AMNIOFILL 500MG
|
Facility
|
IP
|
$21,875.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
AMNIOFILL 500MG
|
Facility
|
OP
|
$21,875.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,562.50 |
| Max. Negotiated Rate |
$21,000.00 |
| Rate for Payer: Aetna Commercial |
$16,843.75
|
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem Medicaid |
$7,522.81
|
| Rate for Payer: Anthem Medicaid |
$2,349.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,062.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$10,937.50
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: Cigna Commercial |
$18,156.25
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: First Health Commercial |
$20,781.25
|
| Rate for Payer: Humana Commercial |
$18,593.75
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana KY Medicaid |
$7,522.81
|
| Rate for Payer: Humana KY Medicaid |
$2,349.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,373.61
|
| Rate for Payer: Kentucky WC Medicaid |
$7,599.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,937.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,143.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,673.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,250.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$16,406.25
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,031.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,093.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: PHCS Commercial |
$21,000.00
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
| Rate for Payer: United Healthcare All Payer |
$19,250.00
|
|
|
AMNIOFIX 7CM*6CM
|
Facility
|
OP
|
$10,278.10
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,083.43 |
| Max. Negotiated Rate |
$9,866.98 |
| Rate for Payer: Aetna Commercial |
$7,914.14
|
| Rate for Payer: Anthem Medicaid |
$3,534.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,016.92
|
| Rate for Payer: Cash Price |
$5,139.05
|
| Rate for Payer: Cigna Commercial |
$8,530.82
|
| Rate for Payer: First Health Commercial |
$9,764.19
|
| Rate for Payer: Humana Commercial |
$8,736.39
|
| Rate for Payer: Humana KY Medicaid |
$3,534.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3,570.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,428.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,585.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,083.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,605.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,044.73
|
| Rate for Payer: Ohio Health Group HMO |
$7,708.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,222.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,941.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,091.89
|
| Rate for Payer: PHCS Commercial |
$9,866.98
|
| Rate for Payer: United Healthcare All Payer |
$9,044.73
|
|
|
AMNIOFIX 7CM*6CM
|
Facility
|
IP
|
$10,278.10
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,083.43 |
| Max. Negotiated Rate |
$9,866.98 |
| Rate for Payer: Aetna Commercial |
$7,914.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,016.92
|
| Rate for Payer: Cash Price |
$5,139.05
|
| Rate for Payer: Cigna Commercial |
$8,530.82
|
| Rate for Payer: First Health Commercial |
$9,764.19
|
| Rate for Payer: Humana Commercial |
$8,736.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,428.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,585.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,083.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,044.73
|
| Rate for Payer: Ohio Health Group HMO |
$7,708.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,222.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,941.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,091.89
|
| Rate for Payer: PHCS Commercial |
$9,866.98
|
| Rate for Payer: United Healthcare All Payer |
$9,044.73
|
|
|
AMNIOMATRIX ALLOGFT SUSP 1.0ML
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
AMNIOMATRIX ALLOGFT SUSP 1.0ML
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
AMNIOMATRIX ALLOGFT SUSP 2.0ML
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
AMNIOMATRIX ALLOGFT SUSP 2.0ML
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
AMNIOMATRIX ALLOGFT SUSP 3.0ML
|
Facility
|
IP
|
$11,207.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
AMNIOMATRIX ALLOGFT SUSP 3.0ML
|
Facility
|
OP
|
$11,207.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem Medicaid |
$3,854.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Humana KY Medicaid |
$3,854.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,893.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,931.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
AMNION MATRIX- THICK 2*2
|
Facility
|
OP
|
$7,316.12
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,194.84 |
| Max. Negotiated Rate |
$7,023.48 |
| Rate for Payer: Aetna Commercial |
$5,633.41
|
| Rate for Payer: Anthem Medicaid |
$2,516.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,706.57
|
| Rate for Payer: Cash Price |
$3,658.06
|
| Rate for Payer: Cigna Commercial |
$6,072.38
|
| Rate for Payer: First Health Commercial |
$6,950.31
|
| Rate for Payer: Humana Commercial |
$6,218.70
|
| Rate for Payer: Humana KY Medicaid |
$2,516.01
|
| Rate for Payer: Kentucky WC Medicaid |
$2,541.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,999.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,399.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,194.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,566.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,438.19
|
| Rate for Payer: Ohio Health Group HMO |
$5,487.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,852.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,365.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,048.12
|
| Rate for Payer: PHCS Commercial |
$7,023.48
|
| Rate for Payer: United Healthcare All Payer |
$6,438.19
|
|
|
AMNION MATRIX- THICK 2*2
|
Facility
|
IP
|
$7,316.12
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,194.84 |
| Max. Negotiated Rate |
$7,023.48 |
| Rate for Payer: Aetna Commercial |
$5,633.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,706.57
|
| Rate for Payer: Cash Price |
$3,658.06
|
| Rate for Payer: Cigna Commercial |
$6,072.38
|
| Rate for Payer: First Health Commercial |
$6,950.31
|
| Rate for Payer: Humana Commercial |
$6,218.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,999.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,399.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,194.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,438.19
|
| Rate for Payer: Ohio Health Group HMO |
$5,487.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,852.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,365.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,048.12
|
| Rate for Payer: PHCS Commercial |
$7,023.48
|
| Rate for Payer: United Healthcare All Payer |
$6,438.19
|
|
|
AMNION MATRIX- THICK 2*3
|
Facility
|
IP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,761.50 |
| Max. Negotiated Rate |
$8,836.80 |
| Rate for Payer: Aetna Commercial |
$7,087.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,179.90
|
| Rate for Payer: Cash Price |
$4,602.50
|
| Rate for Payer: Cigna Commercial |
$7,640.15
|
| Rate for Payer: First Health Commercial |
$8,744.75
|
| Rate for Payer: Humana Commercial |
$7,824.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,548.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,793.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,761.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,100.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,903.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,008.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,351.45
|
| Rate for Payer: PHCS Commercial |
$8,836.80
|
| Rate for Payer: United Healthcare All Payer |
$8,100.40
|
|
|
AMNION MATRIX- THICK 2*3
|
Facility
|
OP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,761.50 |
| Max. Negotiated Rate |
$8,836.80 |
| Rate for Payer: Aetna Commercial |
$7,087.85
|
| Rate for Payer: Anthem Medicaid |
$3,165.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,179.90
|
| Rate for Payer: Cash Price |
$4,602.50
|
| Rate for Payer: Cigna Commercial |
$7,640.15
|
| Rate for Payer: First Health Commercial |
$8,744.75
|
| Rate for Payer: Humana Commercial |
$7,824.25
|
| Rate for Payer: Humana KY Medicaid |
$3,165.60
|
| Rate for Payer: Kentucky WC Medicaid |
$3,197.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,548.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,793.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,761.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,229.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,100.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,903.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,008.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,351.45
|
| Rate for Payer: PHCS Commercial |
$8,836.80
|
| Rate for Payer: United Healthcare All Payer |
$8,100.40
|
|
|
AMNION MATRIX- THICK 3*3
|
Facility
|
IP
|
$12,491.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,747.45 |
| Max. Negotiated Rate |
$11,991.84 |
| Rate for Payer: Aetna Commercial |
$9,618.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,743.37
|
| Rate for Payer: Cash Price |
$6,245.75
|
| Rate for Payer: Cigna Commercial |
$10,367.94
|
| Rate for Payer: First Health Commercial |
$11,866.92
|
| Rate for Payer: Humana Commercial |
$10,617.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,243.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,218.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,747.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,992.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,368.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,993.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,867.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,619.14
|
| Rate for Payer: PHCS Commercial |
$11,991.84
|
| Rate for Payer: United Healthcare All Payer |
$10,992.52
|
|
