|
AMNIOMATRIX ALLOGFT SUSP 2.0ML
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
AMNIOMATRIX ALLOGFT SUSP 2.0ML
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
AMNIOMATRIX ALLOGFT SUSP 3.0ML
|
Facility
|
IP
|
$10,965.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
AMNIOMATRIX ALLOGFT SUSP 3.0ML
|
Facility
|
OP
|
$10,965.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
27000190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem Medicaid |
$3,770.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Humana KY Medicaid |
$3,770.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,809.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,846.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
AMNION MATRIX- THICK 2*2
|
Facility
|
OP
|
$7,116.12
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$925.10 |
| Max. Negotiated Rate |
$6,831.48 |
| Rate for Payer: Aetna Commercial |
$5,479.41
|
| Rate for Payer: Anthem Medicaid |
$2,447.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,550.57
|
| Rate for Payer: Cash Price |
$3,558.06
|
| Rate for Payer: Cigna Commercial |
$5,906.38
|
| Rate for Payer: First Health Commercial |
$6,760.31
|
| Rate for Payer: Humana Commercial |
$6,048.70
|
| Rate for Payer: Humana KY Medicaid |
$2,447.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,472.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,835.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,251.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,134.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,496.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,262.19
|
| Rate for Payer: Ohio Health Group HMO |
$5,337.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,423.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$925.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,206.00
|
| Rate for Payer: PHCS Commercial |
$6,831.48
|
| Rate for Payer: United Healthcare All Payer |
$6,262.19
|
|
|
AMNION MATRIX- THICK 2*2
|
Facility
|
IP
|
$7,116.12
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$925.10 |
| Max. Negotiated Rate |
$6,831.48 |
| Rate for Payer: Aetna Commercial |
$5,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,550.57
|
| Rate for Payer: Cash Price |
$3,558.06
|
| Rate for Payer: Cigna Commercial |
$5,906.38
|
| Rate for Payer: First Health Commercial |
$6,760.31
|
| Rate for Payer: Humana Commercial |
$6,048.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,835.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,251.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,134.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,262.19
|
| Rate for Payer: Ohio Health Group HMO |
$5,337.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,423.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$925.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,206.00
|
| Rate for Payer: PHCS Commercial |
$6,831.48
|
| Rate for Payer: United Healthcare All Payer |
$6,262.19
|
|
|
AMNION MATRIX- THICK 2*3
|
Facility
|
OP
|
$9,005.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.65 |
| Max. Negotiated Rate |
$8,644.80 |
| Rate for Payer: Aetna Commercial |
$6,933.85
|
| Rate for Payer: Anthem Medicaid |
$3,096.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,023.90
|
| Rate for Payer: Cash Price |
$4,502.50
|
| Rate for Payer: Cigna Commercial |
$7,474.15
|
| Rate for Payer: First Health Commercial |
$8,554.75
|
| Rate for Payer: Humana Commercial |
$7,654.25
|
| Rate for Payer: Humana KY Medicaid |
$3,096.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,128.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,384.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,645.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,701.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,158.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,924.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,753.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,801.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,170.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,791.55
|
| Rate for Payer: PHCS Commercial |
$8,644.80
|
| Rate for Payer: United Healthcare All Payer |
$7,924.40
|
|
|
AMNION MATRIX- THICK 2*3
|
Facility
|
IP
|
$9,005.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.65 |
| Max. Negotiated Rate |
$8,644.80 |
| Rate for Payer: Aetna Commercial |
$6,933.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,023.90
|
| Rate for Payer: Cash Price |
$4,502.50
|
| Rate for Payer: Cigna Commercial |
$7,474.15
|
| Rate for Payer: First Health Commercial |
$8,554.75
|
| Rate for Payer: Humana Commercial |
$7,654.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,384.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,645.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,701.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,924.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,753.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,801.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,170.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,791.55
|
| Rate for Payer: PHCS Commercial |
$8,644.80
|
| Rate for Payer: United Healthcare All Payer |
$7,924.40
|
|
|
AMNION MATRIX- THICK 3*3
|
Facility
|
IP
|
$12,242.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,591.52 |
| Max. Negotiated Rate |
$11,752.80 |
| Rate for Payer: Aetna Commercial |
$9,426.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,549.15
|
| Rate for Payer: Cash Price |
$6,121.25
|
| Rate for Payer: Cigna Commercial |
$10,161.28
|
| Rate for Payer: First Health Commercial |
$11,630.38
|
| Rate for Payer: Humana Commercial |
$10,406.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,038.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,034.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,672.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,773.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,181.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,448.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,591.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,795.18
|
| Rate for Payer: PHCS Commercial |
$11,752.80
|
| Rate for Payer: United Healthcare All Payer |
$10,773.40
|
|
|
AMNION MATRIX- THICK 3*3
|
Facility
|
OP
|
$12,242.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,591.52 |
| Max. Negotiated Rate |
$11,752.80 |
| Rate for Payer: Aetna Commercial |
$9,426.72
|
| Rate for Payer: Anthem Medicaid |
$4,210.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,549.15
|
| Rate for Payer: Cash Price |
$6,121.25
|
| Rate for Payer: Cigna Commercial |
$10,161.28
|
| Rate for Payer: First Health Commercial |
$11,630.38
|
| Rate for Payer: Humana Commercial |
$10,406.12
|
| Rate for Payer: Humana KY Medicaid |
$4,210.20
|
| Rate for Payer: Kentucky WC Medicaid |
$4,253.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,038.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,034.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,672.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,294.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,773.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,181.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,448.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,591.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,795.18
|
| Rate for Payer: PHCS Commercial |
$11,752.80
|
| Rate for Payer: United Healthcare All Payer |
$10,773.40
|
|
|
AMNION MATRIX- THICK 3*4
|
Facility
|
IP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
AMNION MATRIX- THICK 3*4
|
Facility
|
OP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem Medicaid |
$4,649.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Humana KY Medicaid |
$4,649.53
|
| Rate for Payer: Kentucky WC Medicaid |
$4,696.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
AMNION MATRIX- THICK 3*6CM
|
Facility
|
IP
|
$17,520.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,277.60 |
| Max. Negotiated Rate |
$16,819.20 |
| Rate for Payer: Aetna Commercial |
$13,490.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,665.60
|
| Rate for Payer: Cash Price |
$8,760.00
|
| Rate for Payer: Cigna Commercial |
$14,541.60
|
| Rate for Payer: First Health Commercial |
$16,644.00
|
| Rate for Payer: Humana Commercial |
$14,892.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,366.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,929.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,256.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,417.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,277.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,431.20
|
| Rate for Payer: PHCS Commercial |
$16,819.20
|
| Rate for Payer: United Healthcare All Payer |
$15,417.60
|
|
|
AMNION MATRIX- THICK 3*6CM
|
Facility
|
OP
|
$17,520.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,277.60 |
| Max. Negotiated Rate |
$16,819.20 |
| Rate for Payer: Aetna Commercial |
$13,490.40
|
| Rate for Payer: Anthem Medicaid |
$6,025.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,665.60
|
| Rate for Payer: Cash Price |
$8,760.00
|
| Rate for Payer: Cigna Commercial |
$14,541.60
|
| Rate for Payer: First Health Commercial |
$16,644.00
|
| Rate for Payer: Humana Commercial |
$14,892.00
|
| Rate for Payer: Humana KY Medicaid |
$6,025.13
|
| Rate for Payer: Kentucky WC Medicaid |
$6,086.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,366.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,929.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,256.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,146.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,417.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,277.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,431.20
|
| Rate for Payer: PHCS Commercial |
$16,819.20
|
| Rate for Payer: United Healthcare All Payer |
$15,417.60
|
|
|
AMNION MATRIX- THICK 3*8
|
Facility
|
OP
|
$20,860.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.80 |
| Max. Negotiated Rate |
$20,025.60 |
| Rate for Payer: Aetna Commercial |
$16,062.20
|
| Rate for Payer: Anthem Medicaid |
$7,173.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,270.80
|
| Rate for Payer: Cash Price |
$10,430.00
|
| Rate for Payer: Cigna Commercial |
$17,313.80
|
| Rate for Payer: First Health Commercial |
$19,817.00
|
| Rate for Payer: Humana Commercial |
$17,731.00
|
| Rate for Payer: Humana KY Medicaid |
$7,173.75
|
| Rate for Payer: Kentucky WC Medicaid |
$7,246.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,105.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,394.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,258.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,317.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,356.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,466.60
|
| Rate for Payer: PHCS Commercial |
$20,025.60
|
| Rate for Payer: United Healthcare All Payer |
$18,356.80
|
|
|
AMNION MATRIX- THICK 3*8
|
Facility
|
IP
|
$20,860.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.80 |
| Max. Negotiated Rate |
$20,025.60 |
| Rate for Payer: Aetna Commercial |
$16,062.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,270.80
|
| Rate for Payer: Cash Price |
$10,430.00
|
| Rate for Payer: Cigna Commercial |
$17,313.80
|
| Rate for Payer: First Health Commercial |
$19,817.00
|
| Rate for Payer: Humana Commercial |
$17,731.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,105.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,394.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,258.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,356.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,466.60
|
| Rate for Payer: PHCS Commercial |
$20,025.60
|
| Rate for Payer: United Healthcare All Payer |
$18,356.80
|
|
|
AMNION MATRIX- THIN 2*12
|
Facility
|
IP
|
$15,090.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.70 |
| Max. Negotiated Rate |
$14,486.40 |
| Rate for Payer: Aetna Commercial |
$11,619.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,770.20
|
| Rate for Payer: Cash Price |
$7,545.00
|
| Rate for Payer: Cigna Commercial |
$12,524.70
|
| Rate for Payer: First Health Commercial |
$14,335.50
|
| Rate for Payer: Humana Commercial |
$12,826.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,373.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,136.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,317.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,018.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,961.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,677.90
|
| Rate for Payer: PHCS Commercial |
$14,486.40
|
| Rate for Payer: United Healthcare All Payer |
$13,279.20
|
|
|
AMNION MATRIX- THIN 2*12
|
Facility
|
OP
|
$15,090.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.70 |
| Max. Negotiated Rate |
$14,486.40 |
| Rate for Payer: Aetna Commercial |
$11,619.30
|
| Rate for Payer: Anthem Medicaid |
$5,189.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,770.20
|
| Rate for Payer: Cash Price |
$7,545.00
|
| Rate for Payer: Cigna Commercial |
$12,524.70
|
| Rate for Payer: First Health Commercial |
$14,335.50
|
| Rate for Payer: Humana Commercial |
$12,826.50
|
| Rate for Payer: Humana KY Medicaid |
$5,189.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,242.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,373.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,136.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,293.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,317.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,018.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,961.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,677.90
|
| Rate for Payer: PHCS Commercial |
$14,486.40
|
| Rate for Payer: United Healthcare All Payer |
$13,279.20
|
|
|
AMNION MATRIX- THIN 2*3CM
|
Facility
|
IP
|
$6,997.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$909.68 |
| Max. Negotiated Rate |
$6,717.60 |
| Rate for Payer: Aetna Commercial |
$5,388.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,458.05
|
| Rate for Payer: Cash Price |
$3,498.75
|
| Rate for Payer: Cigna Commercial |
$5,807.92
|
| Rate for Payer: First Health Commercial |
$6,647.62
|
| Rate for Payer: Humana Commercial |
$5,947.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,737.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,164.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,099.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,157.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,248.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,399.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$909.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,169.22
|
| Rate for Payer: PHCS Commercial |
$6,717.60
|
| Rate for Payer: United Healthcare All Payer |
$6,157.80
|
|
|
AMNION MATRIX- THIN 2*3CM
|
Facility
|
OP
|
$6,997.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$909.68 |
| Max. Negotiated Rate |
$6,717.60 |
| Rate for Payer: Aetna Commercial |
$5,388.08
|
| Rate for Payer: Anthem Medicaid |
$2,406.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,458.05
|
| Rate for Payer: Cash Price |
$3,498.75
|
| Rate for Payer: Cigna Commercial |
$5,807.92
|
| Rate for Payer: First Health Commercial |
$6,647.62
|
| Rate for Payer: Humana Commercial |
$5,947.88
|
| Rate for Payer: Humana KY Medicaid |
$2,406.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,430.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,737.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,164.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,099.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,454.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,157.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,248.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,399.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$909.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,169.22
|
| Rate for Payer: PHCS Commercial |
$6,717.60
|
| Rate for Payer: United Healthcare All Payer |
$6,157.80
|
|
|
AMNION MATRIX- THIN 4*4
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
AMNION MATRIX- THIN 4*4
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
AMNION MATRIX- THIN 4*6
|
Facility
|
IP
|
$15,090.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.70 |
| Max. Negotiated Rate |
$14,486.40 |
| Rate for Payer: Aetna Commercial |
$11,619.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,770.20
|
| Rate for Payer: Cash Price |
$7,545.00
|
| Rate for Payer: Cigna Commercial |
$12,524.70
|
| Rate for Payer: First Health Commercial |
$14,335.50
|
| Rate for Payer: Humana Commercial |
$12,826.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,373.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,136.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,317.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,018.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,961.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,677.90
|
| Rate for Payer: PHCS Commercial |
$14,486.40
|
| Rate for Payer: United Healthcare All Payer |
$13,279.20
|
|
|
AMNION MATRIX- THIN 4*6
|
Facility
|
OP
|
$15,090.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,961.70 |
| Max. Negotiated Rate |
$14,486.40 |
| Rate for Payer: Aetna Commercial |
$11,619.30
|
| Rate for Payer: Anthem Medicaid |
$5,189.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,770.20
|
| Rate for Payer: Cash Price |
$7,545.00
|
| Rate for Payer: Cigna Commercial |
$12,524.70
|
| Rate for Payer: First Health Commercial |
$14,335.50
|
| Rate for Payer: Humana Commercial |
$12,826.50
|
| Rate for Payer: Humana KY Medicaid |
$5,189.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,242.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,373.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,136.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,293.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,317.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,018.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,961.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,677.90
|
| Rate for Payer: PHCS Commercial |
$14,486.40
|
| Rate for Payer: United Healthcare All Payer |
$13,279.20
|
|
|
AMNION MATRIX- THIN 4*8
|
Facility
|
IP
|
$17,610.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,289.30 |
| Max. Negotiated Rate |
$16,905.60 |
| Rate for Payer: Aetna Commercial |
$13,559.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,735.80
|
| Rate for Payer: Cash Price |
$8,805.00
|
| Rate for Payer: Cigna Commercial |
$14,616.30
|
| Rate for Payer: First Health Commercial |
$16,729.50
|
| Rate for Payer: Humana Commercial |
$14,968.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,440.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,996.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,283.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,496.80
|
| Rate for Payer: Ohio Health Group HMO |
$13,207.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,522.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,289.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,459.10
|
| Rate for Payer: PHCS Commercial |
$16,905.60
|
| Rate for Payer: United Healthcare All Payer |
$15,496.80
|
|
