|
LEGION ISRT HK RP SZ 4-5 21MM
|
Facility
|
OP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem Medicaid |
$4,157.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Humana KY Medicaid |
$4,157.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 4-5 21MM
|
Facility
|
IP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 6-7 11MM
|
Facility
|
IP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 6-7 11MM
|
Facility
|
OP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem Medicaid |
$4,157.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Humana KY Medicaid |
$4,157.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 6-7 13MM
|
Facility
|
IP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 6-7 13MM
|
Facility
|
OP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem Medicaid |
$4,157.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Humana KY Medicaid |
$4,157.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 6-7 15MM
|
Facility
|
OP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem Medicaid |
$4,157.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Humana KY Medicaid |
$4,157.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION ISRT HK RP SZ 6-7 15MM
|
Facility
|
IP
|
$12,089.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,571.60 |
| Max. Negotiated Rate |
$11,605.63 |
| Rate for Payer: Aetna Commercial |
$9,308.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,429.58
|
| Rate for Payer: Cash Price |
$6,044.60
|
| Rate for Payer: Cigna Commercial |
$10,034.04
|
| Rate for Payer: First Health Commercial |
$11,484.74
|
| Rate for Payer: Humana Commercial |
$10,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,913.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,921.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,638.50
|
| Rate for Payer: Ohio Health Group HMO |
$9,066.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,417.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,571.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.65
|
| Rate for Payer: PHCS Commercial |
$11,605.63
|
| Rate for Payer: United Healthcare All Payer |
$10,638.50
|
|
|
LEGION L-WEDGE SZ 2 10X5
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 2 10X5
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 2 15X5
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 2 15X5
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 2 5X5
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 2 5X5
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 10X10
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 10X10
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 10X5
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 10X5
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 15X10
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 15X10
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 15X5
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 15X5
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 5X10
|
Facility
|
IP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 5X10
|
Facility
|
OP
|
$6,535.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$6,273.99 |
| Rate for Payer: Aetna Commercial |
$5,032.27
|
| Rate for Payer: Anthem Medicaid |
$2,247.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.62
|
| Rate for Payer: Cash Price |
$3,267.70
|
| Rate for Payer: Cigna Commercial |
$5,424.39
|
| Rate for Payer: First Health Commercial |
$6,208.64
|
| Rate for Payer: Humana Commercial |
$5,555.10
|
| Rate for Payer: Humana KY Medicaid |
$2,247.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,359.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,823.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,751.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,307.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,025.98
|
| Rate for Payer: PHCS Commercial |
$6,273.99
|
| Rate for Payer: United Healthcare All Payer |
$5,751.16
|
|
|
LEGION L-WEDGE SZ 3 5X5
|
Facility
|
IP
|
$13,100.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,703.03 |
| Max. Negotiated Rate |
$12,576.24 |
| Rate for Payer: Aetna Commercial |
$10,087.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,218.20
|
| Rate for Payer: Cash Price |
$6,550.12
|
| Rate for Payer: Cigna Commercial |
$10,873.21
|
| Rate for Payer: First Health Commercial |
$12,445.24
|
| Rate for Payer: Humana Commercial |
$11,135.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,742.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,667.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,930.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,528.22
|
| Rate for Payer: Ohio Health Group HMO |
$9,825.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,620.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,703.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,061.08
|
| Rate for Payer: PHCS Commercial |
$12,576.24
|
| Rate for Payer: United Healthcare All Payer |
$11,528.22
|
|
