|
DYNASTY BF SHELL 60MM 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
|
|
|
DYNASTY BF SHELL 60MM 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 62MM 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
|
|
|
DYNASTY BF SHELL 62MM 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 64MM GROUP H
|
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 64MM GROUP H
|
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 66MM GROUP H
|
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 66MM GROUP H
|
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 68MM GROUP H
|
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 68MM GROUP H
|
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 70MM GROUP J
|
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 70MM GROUP J
|
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 72MM GROUP J
|
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 72MM GROUP J
|
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 74MM GROUP J
|
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 74MM GROUP J
|
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 76MM GROUP K
|
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 76MM GROUP K
|
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 SHEL PRI 46MM GRP 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 SHEL PRI 46MM GRP 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 SHEL PRI 48MM GRP 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 SHEL PRI 48MM GRP 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 SHEL PRI 50MM GRP 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 SHEL PRI 50MM GRP 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 SHEL PRI 52MM GRP 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
|
|
