|
LGN POROUS CR FEM SZ 5 L
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 5 L
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 5 LT
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR FEM SZ 5 LT
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR FEM SZ 5 R
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 5 R
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 6 L
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 6 L
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 6 R
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 6 R
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 7 L
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 7 L
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 7 LT
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR FEM SZ 7 LT
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR FEM SZ 7 R
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 7 R
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 8 L
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 8 L
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 8 R
|
Facility
|
OP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem Medicaid |
$8,677.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Humana KY Medicaid |
$8,677.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8,765.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,851.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR FEM SZ 8 R
|
Facility
|
IP
|
$25,231.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,569.38 |
| Max. Negotiated Rate |
$24,222.00 |
| Rate for Payer: Aetna Commercial |
$19,428.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,680.38
|
| Rate for Payer: Cash Price |
$12,615.62
|
| Rate for Payer: Cigna Commercial |
$20,941.94
|
| Rate for Payer: First Health Commercial |
$23,969.69
|
| Rate for Payer: Humana Commercial |
$21,446.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,689.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,620.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,569.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,203.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,923.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,951.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,409.56
|
| Rate for Payer: PHCS Commercial |
$24,222.00
|
| Rate for Payer: United Healthcare All Payer |
$22,203.50
|
|
|
LGN POROUS CR HA FEM SZ 2 RT
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR HA FEM SZ 2 RT
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR HA FEM SZ 3 RT
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR HA FEM SZ 3 RT
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LGN POROUS CR HA FEM SZ 4 RT
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
