|
LEGION L-WEDGE SZ 3 5X10
|
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 5X10
|
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 5X5
|
Facility
|
OP
|
$13,353.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,006.18 |
| Max. Negotiated Rate |
$12,819.79 |
| Rate for Payer: Aetna Commercial |
$10,282.54
|
| Rate for Payer: Anthem Medicaid |
$4,592.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,416.08
|
| Rate for Payer: Cash Price |
$6,676.98
|
| Rate for Payer: Cigna Commercial |
$11,083.78
|
| Rate for Payer: First Health Commercial |
$12,686.25
|
| Rate for Payer: Humana Commercial |
$11,350.86
|
| Rate for Payer: Humana KY Medicaid |
$4,592.42
|
| Rate for Payer: Kentucky WC Medicaid |
$4,639.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,950.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,855.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,006.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,684.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,751.48
|
| Rate for Payer: Ohio Health Group HMO |
$10,015.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,683.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,617.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,214.23
|
| Rate for Payer: PHCS Commercial |
$12,819.79
|
| Rate for Payer: United Healthcare All Payer |
$11,751.48
|
|
|
LEGION L-WEDGE SZ 3 5X5
|
Facility
|
IP
|
$13,353.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,006.18 |
| Max. Negotiated Rate |
$12,819.79 |
| Rate for Payer: Aetna Commercial |
$10,282.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,416.08
|
| Rate for Payer: Cash Price |
$6,676.98
|
| Rate for Payer: Cigna Commercial |
$11,083.78
|
| Rate for Payer: First Health Commercial |
$12,686.25
|
| Rate for Payer: Humana Commercial |
$11,350.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,950.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,855.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,006.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,751.48
|
| Rate for Payer: Ohio Health Group HMO |
$10,015.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,683.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,617.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,214.23
|
| Rate for Payer: PHCS Commercial |
$12,819.79
|
| Rate for Payer: United Healthcare All Payer |
$11,751.48
|
|
|
LEGION L-WEDGE SZ 4 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 4 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 4 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 4 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 4 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 4 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 4 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 4 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 4 5X10
|
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 4 5X10
|
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 4 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 4 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 5 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 5 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 5 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 5 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 5 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 5 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 5 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 5 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 5 5X10
|
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
|
|
