|
LEGION VISIONAIRE CUT BLCK L
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem Medicaid |
$1,478.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Humana KY Medicaid |
$1,478.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,493.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,508.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISIONAIRE CUT BLCK R
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISIONAIRE CUT BLCK R
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem Medicaid |
$1,478.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Humana KY Medicaid |
$1,478.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,493.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,508.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISIONARE CUT BLCK NS L
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem Medicaid |
$1,478.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Humana KY Medicaid |
$1,478.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,493.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,508.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISIONARE CUT BLCK NS L
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISIONARE CUT BLCK NS R
|
Facility
|
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem Medicaid |
$1,659.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Humana KY Medicaid |
$1,659.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
LEGION VISIONARE CUT BLCK NS R
|
Facility
|
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
LEGION VISNAIR CUTI TIB BLCK R
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISNAIR CUTI TIB BLCK R
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem Medicaid |
$1,478.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Humana KY Medicaid |
$1,478.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,493.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,508.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEGION VISNAIRE CUT TIB BLCK L
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
LEGION VISNAIRE CUT TIB BLCK L
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem Medicaid |
$1,117.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Humana KY Medicaid |
$1,117.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,129.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,140.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
LEGION XLPE DISH INSRT 3-4 9MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INSRT 3-4 9MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INSRT 5-6 9MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INSRT 5-6 9MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INSRT 7-8 9MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INSRT 7-8 9MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 1-2 11MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INST 1-2 11MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INST 1-2 13MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INST 1-2 13MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INST 1-2 15MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 1-2 15MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 3-4 11MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 3-4 11MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
