|
DYNASTY A-CL STD POLY DLXPGE36
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY A-CL STD POLY DLXPGF36
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY A-CL STD POLY DLXPGF36
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY A-CL STD POLY DLXPGG36
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY A-CL STD POLY DLXPGG36
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY A-CL STD POLY DLXPGH36
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY A-CL STD POLY DLXPGH36
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
DYNASTY BF SHELL 46MM GROUP B
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 46MM GROUP B
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 48MM GROUP B
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 48MM GROUP B
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 50MM GROUP C
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 50MM GROUP C
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 52MM GROUP D
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 52MM GROUP D
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 54MM GROUP E
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 54MM GROUP E
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 56MM GROUP F
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 56MM GROUP F
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 58MM GROUP G
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 58MM GROUP G
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 60MM GROUP G
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 60MM GROUP G
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 62MM GROUP G
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
DYNASTY BF SHELL 62MM GROUP G
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
