|
DYNASTY BF SHEL PRI 52MM GRP 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 SHEL PRI 54MM GRP 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 SHEL PRI 54MM GRP 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 SHEL PRI 56MM GRP 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 SHEL PRI 56MM GRP 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 SHEL PRI 58MM GRP 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 SHEL PRI 58MM GRP 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 SHEL PRI 60MM GRP 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 SHEL PRI 60MM GRP 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 SHEL PRI 62MM GRP 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 SHEL PRI 62MM GRP 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 SHEL PRI 64MM GRP 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 SHEL PRI 64MM GRP 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 SHEL PRI 66MM GRP 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 SHEL PRI 66MM GRP 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 SHEL PRI 68MM GRP 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 SHEL PRI 68MM GRP 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
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$8,711.64
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$5,911.47 |
| Max. Negotiated Rate |
$8,711.64 |
| Rate for Payer: Anthem Medicaid |
$5,911.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,222.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,711.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,400.51
|
| Rate for Payer: Humana KY Medicaid |
$5,911.47
|
| Rate for Payer: Humana Medicare Advantage |
$6,222.60
|
| Rate for Payer: Kentucky WC Medicaid |
$5,970.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,467.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,029.70
|
|
|
DYSPL CUP HAP 46MM
|
Facility
|
OP
|
$33,498.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,354.76 |
| Max. Negotiated Rate |
$32,158.20 |
| Rate for Payer: Aetna Commercial |
$25,793.55
|
| Rate for Payer: Anthem Medicaid |
$11,520.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,128.53
|
| Rate for Payer: Cash Price |
$16,749.06
|
| Rate for Payer: Cigna Commercial |
$27,803.44
|
| Rate for Payer: First Health Commercial |
$31,823.21
|
| Rate for Payer: Humana Commercial |
$28,473.40
|
| Rate for Payer: Humana KY Medicaid |
$11,520.00
|
| Rate for Payer: Kentucky WC Medicaid |
$11,637.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,468.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,721.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,049.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,751.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,478.35
|
| Rate for Payer: Ohio Health Group HMO |
$25,123.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,699.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,354.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,384.42
|
| Rate for Payer: PHCS Commercial |
$32,158.20
|
| Rate for Payer: United Healthcare All Payer |
$29,478.35
|
|
|
DYSPL CUP HAP 46MM
|
Facility
|
IP
|
$33,498.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,354.76 |
| Max. Negotiated Rate |
$32,158.20 |
| Rate for Payer: Aetna Commercial |
$25,793.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,128.53
|
| Rate for Payer: Cash Price |
$16,749.06
|
| Rate for Payer: Cigna Commercial |
$27,803.44
|
| Rate for Payer: First Health Commercial |
$31,823.21
|
| Rate for Payer: Humana Commercial |
$28,473.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,468.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,721.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,049.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,478.35
|
| Rate for Payer: Ohio Health Group HMO |
$25,123.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,699.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,354.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,384.42
|
| Rate for Payer: PHCS Commercial |
$32,158.20
|
| Rate for Payer: United Healthcare All Payer |
$29,478.35
|
|
|
DYSPL CUP HAP 54MM
|
Facility
|
IP
|
$33,498.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,354.76 |
| Max. Negotiated Rate |
$32,158.20 |
| Rate for Payer: Aetna Commercial |
$25,793.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,128.53
|
| Rate for Payer: Cash Price |
$16,749.06
|
| Rate for Payer: Cigna Commercial |
$27,803.44
|
| Rate for Payer: First Health Commercial |
$31,823.21
|
| Rate for Payer: Humana Commercial |
$28,473.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,468.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,721.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,049.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,478.35
|
| Rate for Payer: Ohio Health Group HMO |
$25,123.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,699.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,354.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,384.42
|
| Rate for Payer: PHCS Commercial |
$32,158.20
|
| Rate for Payer: United Healthcare All Payer |
$29,478.35
|
|
|
DYSPL CUP HAP 54MM
|
Facility
|
OP
|
$33,498.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,354.76 |
| Max. Negotiated Rate |
$32,158.20 |
| Rate for Payer: Aetna Commercial |
$25,793.55
|
| Rate for Payer: Anthem Medicaid |
$11,520.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,128.53
|
| Rate for Payer: Cash Price |
$16,749.06
|
| Rate for Payer: Cigna Commercial |
$27,803.44
|
| Rate for Payer: First Health Commercial |
$31,823.21
|
| Rate for Payer: Humana Commercial |
$28,473.40
|
| Rate for Payer: Humana KY Medicaid |
$11,520.00
|
| Rate for Payer: Kentucky WC Medicaid |
$11,637.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,468.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,721.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,049.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,751.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,478.35
|
| Rate for Payer: Ohio Health Group HMO |
$25,123.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,699.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,354.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,384.42
|
| Rate for Payer: PHCS Commercial |
$32,158.20
|
| Rate for Payer: United Healthcare All Payer |
$29,478.35
|
|
|
DYSPORT
|
Professional
|
Both
|
$4.18
|
|
| Hospital Charge Code |
22200028
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Buckeye Medicare Advantage |
$4.18
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Multiplan PHCS |
$2.51
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2.93
|
| Rate for Payer: UHCCP Medicaid |
$1.46
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
OP
|
$45.11
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem Medicaid |
$15.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.89
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cigna Commercial |
$37.44
|
| Rate for Payer: First Health Commercial |
$42.85
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Humana KY Medicaid |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$8.80
|
| Rate for Payer: Kentucky WC Medicaid |
$15.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.70
|
| Rate for Payer: Ohio Health Group HMO |
$33.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.31
|
| Rate for Payer: United Healthcare All Payer |
$39.70
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
OP
|
$2,809.48
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$2,697.10 |
| Rate for Payer: Cash Price |
$1,404.74
|
| Rate for Payer: Cash Price |
$1,404.74
|
| Rate for Payer: Cigna Commercial |
$2,331.87
|
| Rate for Payer: First Health Commercial |
$2,669.01
|
| Rate for Payer: Humana Commercial |
$2,388.06
|
| Rate for Payer: Humana KY Medicaid |
$966.18
|
| Rate for Payer: Humana Medicare Advantage |
$8.80
|
| Rate for Payer: Kentucky WC Medicaid |
$976.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,303.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,073.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$985.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,472.34
|
| Rate for Payer: Ohio Health Group HMO |
$2,107.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$561.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$870.94
|
| Rate for Payer: PHCS Commercial |
$2,697.10
|
| Rate for Payer: United Healthcare All Payer |
$2,472.34
|
| Rate for Payer: Aetna Commercial |
$2,163.30
|
| Rate for Payer: Anthem Medicaid |
$966.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,191.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.89
|
|
