|
LPS-FLEX GSF OPTION FEM F LT
|
Facility
|
IP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF OPTION FEM F RT
|
Facility
|
IP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF OPTION FEM F RT
|
Facility
|
OP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem Medicaid |
$5,743.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Humana KY Medicaid |
$5,743.99
|
| Rate for Payer: Kentucky WC Medicaid |
$5,802.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF OPTION FEM G LT
|
Facility
|
OP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem Medicaid |
$5,743.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Humana KY Medicaid |
$5,743.99
|
| Rate for Payer: Kentucky WC Medicaid |
$5,802.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF OPTION FEM G LT
|
Facility
|
IP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF OPTION FEM G RT
|
Facility
|
OP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem Medicaid |
$5,743.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Humana KY Medicaid |
$5,743.99
|
| Rate for Payer: Kentucky WC Medicaid |
$5,802.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF OPTION FEM G RT
|
Facility
|
IP
|
$16,702.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,010.75 |
| Max. Negotiated Rate |
$16,034.40 |
| Rate for Payer: Aetna Commercial |
$12,860.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,027.95
|
| Rate for Payer: Cash Price |
$8,351.25
|
| Rate for Payer: Cigna Commercial |
$13,863.08
|
| Rate for Payer: First Health Commercial |
$15,867.38
|
| Rate for Payer: Humana Commercial |
$14,197.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,696.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,326.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,010.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,698.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,526.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,362.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,531.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,524.73
|
| Rate for Payer: PHCS Commercial |
$16,034.40
|
| Rate for Payer: United Healthcare All Payer |
$14,698.20
|
|
|
LPS-FLEX GSF POROUS FEM C LT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM C LT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM C RT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM C RT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM D LT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM D LT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM D RT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM D RT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM E LT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM E LT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM E RT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM E RT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM F LT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM F LT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM F RT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM F RT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM G LT
|
Facility
|
OP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem Medicaid |
$7,845.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Humana KY Medicaid |
$7,845.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,925.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,002.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
|
LPS-FLEX GSF POROUS FEM G LT
|
Facility
|
IP
|
$22,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,843.75 |
| Max. Negotiated Rate |
$21,900.00 |
| Rate for Payer: Aetna Commercial |
$17,565.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,793.75
|
| Rate for Payer: Cash Price |
$11,406.25
|
| Rate for Payer: Cigna Commercial |
$18,934.38
|
| Rate for Payer: First Health Commercial |
$21,671.88
|
| Rate for Payer: Humana Commercial |
$19,390.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,706.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,835.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,843.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,075.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,109.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,846.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,740.62
|
| Rate for Payer: PHCS Commercial |
$21,900.00
|
| Rate for Payer: United Healthcare All Payer |
$20,075.00
|
|
