|
LGN POROUS CR FEM SZ 5 L
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 5 L
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 5 LT
|
Facility
|
OP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem Medicaid |
$6,859.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Humana KY Medicaid |
$6,859.95
|
| Rate for Payer: Kentucky WC Medicaid |
$6,929.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,997.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR FEM SZ 5 LT
|
Facility
|
IP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR FEM SZ 5 R
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 5 R
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 6 L
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 6 L
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 6 R
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 6 R
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 7 L
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 7 L
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 7 LT
|
Facility
|
OP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem Medicaid |
$6,859.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Humana KY Medicaid |
$6,859.95
|
| Rate for Payer: Kentucky WC Medicaid |
$6,929.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,997.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR FEM SZ 7 LT
|
Facility
|
IP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR FEM SZ 7 R
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 7 R
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 8 L
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 8 L
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 8 R
|
Facility
|
IP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR FEM SZ 8 R
|
Facility
|
OP
|
$24,491.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,183.93 |
| Max. Negotiated Rate |
$23,512.08 |
| Rate for Payer: Aetna Commercial |
$18,858.65
|
| Rate for Payer: Anthem Medicaid |
$8,422.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,103.56
|
| Rate for Payer: Cash Price |
$12,245.88
|
| Rate for Payer: Cigna Commercial |
$20,328.15
|
| Rate for Payer: First Health Commercial |
$23,267.16
|
| Rate for Payer: Humana Commercial |
$20,817.99
|
| Rate for Payer: Humana KY Medicaid |
$8,422.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,508.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,083.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,074.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,347.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,591.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,552.74
|
| Rate for Payer: Ohio Health Group HMO |
$18,368.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,898.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,183.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,592.44
|
| Rate for Payer: PHCS Commercial |
$23,512.08
|
| Rate for Payer: United Healthcare All Payer |
$21,552.74
|
|
|
LGN POROUS CR HA FEM SZ 2 RT
|
Facility
|
OP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem Medicaid |
$6,859.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Humana KY Medicaid |
$6,859.95
|
| Rate for Payer: Kentucky WC Medicaid |
$6,929.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,997.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR HA FEM SZ 2 RT
|
Facility
|
IP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR HA FEM SZ 3 RT
|
Facility
|
IP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR HA FEM SZ 3 RT
|
Facility
|
OP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem Medicaid |
$6,859.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Humana KY Medicaid |
$6,859.95
|
| Rate for Payer: Kentucky WC Medicaid |
$6,929.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,997.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
|
LGN POROUS CR HA FEM SZ 4 RT
|
Facility
|
IP
|
$19,947.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,593.18 |
| Max. Negotiated Rate |
$19,149.60 |
| Rate for Payer: Aetna Commercial |
$15,359.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,559.05
|
| Rate for Payer: Cash Price |
$9,973.75
|
| Rate for Payer: Cigna Commercial |
$16,556.42
|
| Rate for Payer: First Health Commercial |
$18,950.12
|
| Rate for Payer: Humana Commercial |
$16,955.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,356.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,721.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,984.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,553.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,960.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,989.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,593.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.72
|
| Rate for Payer: PHCS Commercial |
$19,149.60
|
| Rate for Payer: United Healthcare All Payer |
$17,553.80
|
|
