|
LEGION REV TIB BASE SZ 2 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 2 RT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 2 RT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 3 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 3 LT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 3 RT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 3 RT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 4 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 4 LT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 4 RT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 4 RT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 5 LT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 5 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 5 RT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 5 RT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 6 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 6 LT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 6 RT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 6 RT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 7 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 7 LT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 7 RT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 7 RT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 8 LT
|
Facility
|
IP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
|
LEGION REV TIB BASE SZ 8 LT
|
Facility
|
OP
|
$18,240.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.20 |
| Max. Negotiated Rate |
$17,510.40 |
| Rate for Payer: Aetna Commercial |
$14,044.80
|
| Rate for Payer: Anthem Medicaid |
$6,272.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,227.20
|
| Rate for Payer: Cash Price |
$9,120.00
|
| Rate for Payer: Cigna Commercial |
$15,139.20
|
| Rate for Payer: First Health Commercial |
$17,328.00
|
| Rate for Payer: Humana Commercial |
$15,504.00
|
| Rate for Payer: Humana KY Medicaid |
$6,272.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,336.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,956.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,461.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,472.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,398.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,654.40
|
| Rate for Payer: PHCS Commercial |
$17,510.40
|
| Rate for Payer: United Healthcare All Payer |
$16,051.20
|
|
