|
AMNION MATRIX- THICK 3*3
|
Facility
|
OP
|
$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 Medicaid |
$4,295.83
|
| 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: Humana KY Medicaid |
$4,295.83
|
| Rate for Payer: Kentucky WC Medicaid |
$4,339.55
|
| 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: Molina Healthcare Medicaid |
$4,382.02
|
| 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
|
|
|
AMNION MATRIX- THICK 3*4
|
Facility
|
IP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
AMNION MATRIX- THICK 3*4
|
Facility
|
OP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem Medicaid |
$4,737.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Humana KY Medicaid |
$4,737.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,785.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,832.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
AMNION MATRIX- THICK 3*6CM
|
Facility
|
IP
|
$18,090.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,427.00 |
| Max. Negotiated Rate |
$17,366.40 |
| Rate for Payer: Aetna Commercial |
$13,929.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,110.20
|
| Rate for Payer: Cash Price |
$9,045.00
|
| Rate for Payer: Cigna Commercial |
$15,014.70
|
| Rate for Payer: First Health Commercial |
$17,185.50
|
| Rate for Payer: Humana Commercial |
$15,376.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,833.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,350.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,427.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,919.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,567.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,472.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,738.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,482.10
|
| Rate for Payer: PHCS Commercial |
$17,366.40
|
| Rate for Payer: United Healthcare All Payer |
$15,919.20
|
|
|
AMNION MATRIX- THICK 3*6CM
|
Facility
|
OP
|
$18,090.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,427.00 |
| Max. Negotiated Rate |
$17,366.40 |
| Rate for Payer: Aetna Commercial |
$13,929.30
|
| Rate for Payer: Anthem Medicaid |
$6,221.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,110.20
|
| Rate for Payer: Cash Price |
$9,045.00
|
| Rate for Payer: Cigna Commercial |
$15,014.70
|
| Rate for Payer: First Health Commercial |
$17,185.50
|
| Rate for Payer: Humana Commercial |
$15,376.50
|
| Rate for Payer: Humana KY Medicaid |
$6,221.15
|
| Rate for Payer: Kentucky WC Medicaid |
$6,284.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,833.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,350.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,427.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,345.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,919.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,567.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,472.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,738.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,482.10
|
| Rate for Payer: PHCS Commercial |
$17,366.40
|
| Rate for Payer: United Healthcare All Payer |
$15,919.20
|
|
|
AMNION MATRIX- THICK 3*8
|
Facility
|
OP
|
$21,500.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,450.00 |
| Max. Negotiated Rate |
$20,640.00 |
| Rate for Payer: Aetna Commercial |
$16,555.00
|
| Rate for Payer: Anthem Medicaid |
$7,393.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,770.00
|
| Rate for Payer: Cash Price |
$10,750.00
|
| Rate for Payer: Cigna Commercial |
$17,845.00
|
| Rate for Payer: First Health Commercial |
$20,425.00
|
| Rate for Payer: Humana Commercial |
$18,275.00
|
| Rate for Payer: Humana KY Medicaid |
$7,393.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,469.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,630.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,867.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,450.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,542.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,920.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,705.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,835.00
|
| Rate for Payer: PHCS Commercial |
$20,640.00
|
| Rate for Payer: United Healthcare All Payer |
$18,920.00
|
|
|
AMNION MATRIX- THICK 3*8
|
Facility
|
IP
|
$21,500.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,450.00 |
| Max. Negotiated Rate |
$20,640.00 |
| Rate for Payer: Aetna Commercial |
$16,555.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,770.00
|
| Rate for Payer: Cash Price |
$10,750.00
|
| Rate for Payer: Cigna Commercial |
$17,845.00
|
| Rate for Payer: First Health Commercial |
$20,425.00
|
| Rate for Payer: Humana Commercial |
$18,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,630.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,867.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,920.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,705.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,835.00
|
| Rate for Payer: PHCS Commercial |
$20,640.00
|
| Rate for Payer: United Healthcare All Payer |
$18,920.00
|
|
|
AMNION MATRIX- THIN 2*12
|
Facility
|
OP
|
$15,592.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,677.75 |
| Max. Negotiated Rate |
$14,968.80 |
| Rate for Payer: Aetna Commercial |
$12,006.23
|
| Rate for Payer: Anthem Medicaid |
$5,362.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,162.15
|
| Rate for Payer: Cash Price |
$7,796.25
|
| Rate for Payer: Cigna Commercial |
$12,941.77
|
| Rate for Payer: First Health Commercial |
$14,812.88
|
| Rate for Payer: Humana Commercial |
$13,253.62
|
| Rate for Payer: Humana KY Medicaid |
$5,362.26
|
| Rate for Payer: Kentucky WC Medicaid |
$5,416.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,785.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,507.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,677.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,469.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,721.40
|
| Rate for Payer: Ohio Health Group HMO |
$11,694.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,474.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,565.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,758.83
|
| Rate for Payer: PHCS Commercial |
$14,968.80
|
| Rate for Payer: United Healthcare All Payer |
$13,721.40
|
|
|
AMNION MATRIX- THIN 2*12
|
Facility
|
IP
|
$15,592.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,677.75 |
| Max. Negotiated Rate |
$14,968.80 |
| Rate for Payer: Aetna Commercial |
$12,006.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,162.15
|
| Rate for Payer: Cash Price |
$7,796.25
|
| Rate for Payer: Cigna Commercial |
$12,941.77
|
| Rate for Payer: First Health Commercial |
$14,812.88
|
| Rate for Payer: Humana Commercial |
$13,253.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,785.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,507.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,677.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,721.40
|
| Rate for Payer: Ohio Health Group HMO |
$11,694.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,474.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,565.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,758.83
|
| Rate for Payer: PHCS Commercial |
$14,968.80
|
| Rate for Payer: United Healthcare All Payer |
$13,721.40
|
|
|
AMNION MATRIX- THIN 2*3CM
|
Facility
|
OP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem Medicaid |
$2,475.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Humana KY Medicaid |
$2,475.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,524.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
AMNION MATRIX- THIN 2*3CM
|
Facility
|
IP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
AMNION MATRIX- THIN 4*4
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
AMNION MATRIX- THIN 4*4
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
AMNION MATRIX- THIN 4*6
|
Facility
|
OP
|
$15,592.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,677.75 |
| Max. Negotiated Rate |
$14,968.80 |
| Rate for Payer: Aetna Commercial |
$12,006.23
|
| Rate for Payer: Anthem Medicaid |
$5,362.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,162.15
|
| Rate for Payer: Cash Price |
$7,796.25
|
| Rate for Payer: Cigna Commercial |
$12,941.77
|
| Rate for Payer: First Health Commercial |
$14,812.88
|
| Rate for Payer: Humana Commercial |
$13,253.62
|
| Rate for Payer: Humana KY Medicaid |
$5,362.26
|
| Rate for Payer: Kentucky WC Medicaid |
$5,416.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,785.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,507.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,677.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,469.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,721.40
|
| Rate for Payer: Ohio Health Group HMO |
$11,694.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,474.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,565.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,758.83
|
| Rate for Payer: PHCS Commercial |
$14,968.80
|
| Rate for Payer: United Healthcare All Payer |
$13,721.40
|
|
|
AMNION MATRIX- THIN 4*6
|
Facility
|
IP
|
$15,592.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,677.75 |
| Max. Negotiated Rate |
$14,968.80 |
| Rate for Payer: Aetna Commercial |
$12,006.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,162.15
|
| Rate for Payer: Cash Price |
$7,796.25
|
| Rate for Payer: Cigna Commercial |
$12,941.77
|
| Rate for Payer: First Health Commercial |
$14,812.88
|
| Rate for Payer: Humana Commercial |
$13,253.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,785.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,507.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,677.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,721.40
|
| Rate for Payer: Ohio Health Group HMO |
$11,694.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,474.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,565.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,758.83
|
| Rate for Payer: PHCS Commercial |
$14,968.80
|
| Rate for Payer: United Healthcare All Payer |
$13,721.40
|
|
|
AMNION MATRIX- THIN 4*8
|
Facility
|
OP
|
$18,182.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,454.75 |
| Max. Negotiated Rate |
$17,455.20 |
| Rate for Payer: Aetna Commercial |
$14,000.52
|
| Rate for Payer: Anthem Medicaid |
$6,252.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,182.35
|
| Rate for Payer: Cash Price |
$9,091.25
|
| Rate for Payer: Cigna Commercial |
$15,091.48
|
| Rate for Payer: First Health Commercial |
$17,273.38
|
| Rate for Payer: Humana Commercial |
$15,455.12
|
| Rate for Payer: Humana KY Medicaid |
$6,252.96
|
| Rate for Payer: Kentucky WC Medicaid |
$6,316.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,909.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,418.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,454.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,378.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,636.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,546.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,818.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,545.92
|
| Rate for Payer: PHCS Commercial |
$17,455.20
|
| Rate for Payer: United Healthcare All Payer |
$16,000.60
|
|
|
AMNION MATRIX- THIN 4*8
|
Facility
|
IP
|
$18,182.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,454.75 |
| Max. Negotiated Rate |
$17,455.20 |
| Rate for Payer: Aetna Commercial |
$14,000.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,182.35
|
| Rate for Payer: Cash Price |
$9,091.25
|
| Rate for Payer: Cigna Commercial |
$15,091.48
|
| Rate for Payer: First Health Commercial |
$17,273.38
|
| Rate for Payer: Humana Commercial |
$15,455.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,909.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,418.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,454.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,636.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,546.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,818.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,545.92
|
| Rate for Payer: PHCS Commercial |
$17,455.20
|
| Rate for Payer: United Healthcare All Payer |
$16,000.60
|
|
|
AMNION MATRIX- THIN 7*7
|
Facility
|
OP
|
$23,468.75
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,040.62 |
| Max. Negotiated Rate |
$22,530.00 |
| Rate for Payer: Aetna Commercial |
$18,070.94
|
| Rate for Payer: Anthem Medicaid |
$8,070.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,305.62
|
| Rate for Payer: Cash Price |
$11,734.38
|
| Rate for Payer: Cigna Commercial |
$19,479.06
|
| Rate for Payer: First Health Commercial |
$22,295.31
|
| Rate for Payer: Humana Commercial |
$19,948.44
|
| Rate for Payer: Humana KY Medicaid |
$8,070.90
|
| Rate for Payer: Kentucky WC Medicaid |
$8,153.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,244.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,319.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,040.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,232.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,652.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,601.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,775.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,417.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,193.44
|
| Rate for Payer: PHCS Commercial |
$22,530.00
|
| Rate for Payer: United Healthcare All Payer |
$20,652.50
|
|
|
AMNION MATRIX- THIN 7*7
|
Facility
|
IP
|
$23,468.75
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,040.62 |
| Max. Negotiated Rate |
$22,530.00 |
| Rate for Payer: Aetna Commercial |
$18,070.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,305.62
|
| Rate for Payer: Cash Price |
$11,734.38
|
| Rate for Payer: Cigna Commercial |
$19,479.06
|
| Rate for Payer: First Health Commercial |
$22,295.31
|
| Rate for Payer: Humana Commercial |
$19,948.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,244.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,319.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,040.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,652.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,601.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,775.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,417.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,193.44
|
| Rate for Payer: PHCS Commercial |
$22,530.00
|
| Rate for Payer: United Healthcare All Payer |
$20,652.50
|
|
|
AMOXICILLIN 250 MG 250MG/1CAP
|
Facility
|
OP
|
$4.31
|
|
|
Service Code
|
NDC 781202001
|
| Hospital Charge Code |
25000214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
AMOXICILLIN 250 MG 250MG/1CAP
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 781202001
|
| Hospital Charge Code |
25000214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
AMOXICILLIN 250MG/5ML LIQ
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 143988901
|
| Hospital Charge Code |
25000216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
AMOXICILLIN 250MG/5ML LIQ
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 143988901
|
| Hospital Charge Code |
25000216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
AMOXICILLIN 875 TABLET
|
Facility
|
IP
|
$4.85
|
|
|
Service Code
|
NDC 93226401
|
| Hospital Charge Code |
25000218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
AMOXICILLIN 875 TABLET
|
Facility
|
OP
|
$4.85
|
|
|
Service Code
|
NDC 93226401
|
| Hospital Charge Code |
25000218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
