|
DYNASTY A-CL STD LNR 50M GRP J
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD LNR 54M GRP K
|
Facility
|
IP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD LNR 54M GRP K
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGE36
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGE36
|
Facility
|
IP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGF36
|
Facility
|
IP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGF36
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGG36
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGG36
|
Facility
|
IP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGH36
|
Facility
|
IP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY A-CL STD POLY DLXPGH36
|
Facility
|
OP
|
$5,350.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.50 |
| Max. Negotiated Rate |
$5,136.00 |
| Rate for Payer: Aetna Commercial |
$4,119.50
|
| Rate for Payer: Anthem Medicaid |
$1,839.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,173.00
|
| Rate for Payer: Cash Price |
$2,675.00
|
| Rate for Payer: Cigna Commercial |
$4,440.50
|
| Rate for Payer: First Health Commercial |
$5,082.50
|
| Rate for Payer: Humana Commercial |
$4,547.50
|
| Rate for Payer: Humana KY Medicaid |
$1,839.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,858.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,387.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,948.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,876.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,708.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,658.50
|
| Rate for Payer: PHCS Commercial |
$5,136.00
|
| Rate for Payer: United Healthcare All Payer |
$4,708.00
|
|
|
DYNASTY BF SHELL 46MM GROUP B
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 46MM GROUP B
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 48MM GROUP B
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 48MM GROUP B
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 50MM GROUP C
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 50MM GROUP C
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 52MM GROUP D
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 52MM GROUP D
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 54MM GROUP E
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 54MM GROUP E
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 56MM GROUP F
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 56MM GROUP F
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 58MM GROUP G
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
DYNASTY BF SHELL 58MM GROUP G
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
