|
LEGION ISRT HK RP SZ 4-5 15MM
|
Facility
|
IP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 4-5 18MM
|
Facility
|
OP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem Medicaid |
$4,242.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Humana KY Medicaid |
$4,242.82
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,327.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 4-5 18MM
|
Facility
|
IP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 4-5 21MM
|
Facility
|
IP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 4-5 21MM
|
Facility
|
OP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem Medicaid |
$4,242.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Humana KY Medicaid |
$4,242.82
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,327.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 6-7 11MM
|
Facility
|
IP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 6-7 11MM
|
Facility
|
OP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem Medicaid |
$4,242.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Humana KY Medicaid |
$4,242.82
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,327.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 6-7 13MM
|
Facility
|
OP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem Medicaid |
$4,242.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Humana KY Medicaid |
$4,242.82
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,327.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 6-7 13MM
|
Facility
|
IP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 6-7 15MM
|
Facility
|
OP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem Medicaid |
$4,242.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Humana KY Medicaid |
$4,242.82
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,327.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION ISRT HK RP SZ 6-7 15MM
|
Facility
|
IP
|
$12,337.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,701.21 |
| Max. Negotiated Rate |
$11,843.87 |
| Rate for Payer: Aetna Commercial |
$9,499.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,623.14
|
| Rate for Payer: Cash Price |
$6,168.68
|
| Rate for Payer: Cigna Commercial |
$10,240.01
|
| Rate for Payer: First Health Commercial |
$11,720.49
|
| Rate for Payer: Humana Commercial |
$10,486.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,116.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,104.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,856.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,253.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,869.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,733.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,512.78
|
| Rate for Payer: PHCS Commercial |
$11,843.87
|
| Rate for Payer: United Healthcare All Payer |
$10,856.88
|
|
|
LEGION L-WEDGE SZ 2 10X5
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 2 10X5
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 2 15X5
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 2 15X5
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 2 5X5
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 2 5X5
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 10X10
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 10X10
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 10X5
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 10X5
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 15X10
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 15X10
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 15X5
|
Facility
|
IP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
|
LEGION L-WEDGE SZ 3 15X5
|
Facility
|
OP
|
$6,735.41
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,020.62 |
| Max. Negotiated Rate |
$6,465.99 |
| Rate for Payer: Aetna Commercial |
$5,186.27
|
| Rate for Payer: Anthem Medicaid |
$2,316.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,253.62
|
| Rate for Payer: Cash Price |
$3,367.70
|
| Rate for Payer: Cigna Commercial |
$5,590.39
|
| Rate for Payer: First Health Commercial |
$6,398.64
|
| Rate for Payer: Humana Commercial |
$5,725.10
|
| Rate for Payer: Humana KY Medicaid |
$2,316.31
|
| Rate for Payer: Kentucky WC Medicaid |
$2,339.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,523.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,970.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,020.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,362.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,927.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,051.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,388.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,859.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,647.43
|
| Rate for Payer: PHCS Commercial |
$6,465.99
|
| Rate for Payer: United Healthcare All Payer |
$5,927.16
|
|
