|
DYNASTY BF SHEL PRI 56MM GRP 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 SHEL PRI 58MM GRP 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 SHEL PRI 58MM GRP 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 SHEL PRI 60MM GRP 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 SHEL PRI 60MM GRP 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 SHEL PRI 62MM GRP 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 SHEL PRI 62MM GRP 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 SHEL PRI 64MM GRP H
|
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 SHEL PRI 64MM GRP H
|
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 SHEL PRI 66MM GRP H
|
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 SHEL PRI 66MM GRP H
|
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 SHEL PRI 68MM GRP H
|
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 SHEL PRI 68MM GRP H
|
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
|
|
|
DYSPL CUP HAP 46MM
|
Facility
|
OP
|
$34,484.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,345.31 |
| Max. Negotiated Rate |
$33,105.00 |
| Rate for Payer: Aetna Commercial |
$26,552.97
|
| Rate for Payer: Anthem Medicaid |
$11,859.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,897.82
|
| Rate for Payer: Cash Price |
$17,242.19
|
| Rate for Payer: Cigna Commercial |
$28,622.04
|
| Rate for Payer: First Health Commercial |
$32,760.16
|
| Rate for Payer: Humana Commercial |
$29,311.72
|
| Rate for Payer: Humana KY Medicaid |
$11,859.18
|
| Rate for Payer: Kentucky WC Medicaid |
$11,979.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,277.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,449.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,345.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,097.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,346.25
|
| Rate for Payer: Ohio Health Group HMO |
$25,863.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,587.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30,001.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,794.22
|
| Rate for Payer: PHCS Commercial |
$33,105.00
|
| Rate for Payer: United Healthcare All Payer |
$30,346.25
|
|
|
DYSPL CUP HAP 46MM
|
Facility
|
IP
|
$34,484.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,345.31 |
| Max. Negotiated Rate |
$33,105.00 |
| Rate for Payer: Aetna Commercial |
$26,552.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,897.82
|
| Rate for Payer: Cash Price |
$17,242.19
|
| Rate for Payer: Cigna Commercial |
$28,622.04
|
| Rate for Payer: First Health Commercial |
$32,760.16
|
| Rate for Payer: Humana Commercial |
$29,311.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,277.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,449.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,345.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,346.25
|
| Rate for Payer: Ohio Health Group HMO |
$25,863.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,587.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30,001.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,794.22
|
| Rate for Payer: PHCS Commercial |
$33,105.00
|
| Rate for Payer: United Healthcare All Payer |
$30,346.25
|
|
|
DYSPL CUP HAP 54MM
|
Facility
|
OP
|
$34,484.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,345.31 |
| Max. Negotiated Rate |
$33,105.00 |
| Rate for Payer: Aetna Commercial |
$26,552.97
|
| Rate for Payer: Anthem Medicaid |
$11,859.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,897.82
|
| Rate for Payer: Cash Price |
$17,242.19
|
| Rate for Payer: Cigna Commercial |
$28,622.04
|
| Rate for Payer: First Health Commercial |
$32,760.16
|
| Rate for Payer: Humana Commercial |
$29,311.72
|
| Rate for Payer: Humana KY Medicaid |
$11,859.18
|
| Rate for Payer: Kentucky WC Medicaid |
$11,979.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,277.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,449.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,345.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,097.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,346.25
|
| Rate for Payer: Ohio Health Group HMO |
$25,863.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,587.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30,001.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,794.22
|
| Rate for Payer: PHCS Commercial |
$33,105.00
|
| Rate for Payer: United Healthcare All Payer |
$30,346.25
|
|
|
DYSPL CUP HAP 54MM
|
Facility
|
IP
|
$34,484.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,345.31 |
| Max. Negotiated Rate |
$33,105.00 |
| Rate for Payer: Aetna Commercial |
$26,552.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,897.82
|
| Rate for Payer: Cash Price |
$17,242.19
|
| Rate for Payer: Cigna Commercial |
$28,622.04
|
| Rate for Payer: First Health Commercial |
$32,760.16
|
| Rate for Payer: Humana Commercial |
$29,311.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,277.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,449.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,345.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,346.25
|
| Rate for Payer: Ohio Health Group HMO |
$25,863.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,587.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30,001.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,794.22
|
| Rate for Payer: PHCS Commercial |
$33,105.00
|
| Rate for Payer: United Healthcare All Payer |
$30,346.25
|
|
|
DYSPORT
|
Facility
|
IP
|
$4.18
|
|
| Hospital Charge Code |
22200028
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna Commercial |
$3.47
|
| Rate for Payer: First Health Commercial |
$3.97
|
| Rate for Payer: Humana Commercial |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.68
|
| Rate for Payer: Ohio Health Group HMO |
$3.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$4.01
|
| Rate for Payer: United Healthcare All Payer |
$3.68
|
|
|
DYSPORT
|
Facility
|
OP
|
$4.18
|
|
| Hospital Charge Code |
22200028
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.22
|
| Rate for Payer: Anthem Medicaid |
$1.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna Commercial |
$3.47
|
| Rate for Payer: First Health Commercial |
$3.97
|
| Rate for Payer: Humana Commercial |
$3.55
|
| Rate for Payer: Humana KY Medicaid |
$1.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.68
|
| Rate for Payer: Ohio Health Group HMO |
$3.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$4.01
|
| Rate for Payer: United Healthcare All Payer |
$3.68
|
|
|
DYSPORT
|
Professional
|
Both
|
$4.18
|
|
| Hospital Charge Code |
22200028
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.93 |
| 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
|
IP
|
$2,880.33
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$864.10 |
| Max. Negotiated Rate |
$2,765.12 |
| Rate for Payer: Aetna Commercial |
$2,217.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,246.66
|
| Rate for Payer: Cash Price |
$1,440.16
|
| Rate for Payer: Cigna Commercial |
$2,390.67
|
| Rate for Payer: First Health Commercial |
$2,736.31
|
| Rate for Payer: Humana Commercial |
$2,448.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,361.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,125.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$864.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,534.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,160.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,304.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,505.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,987.43
|
| Rate for Payer: PHCS Commercial |
$2,765.12
|
| Rate for Payer: United Healthcare All Payer |
$2,534.69
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
OP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem Medicaid |
$16.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Humana KY Medicaid |
$16.50
|
| Rate for Payer: Humana Medicare Advantage |
$9.17
|
| Rate for Payer: Kentucky WC Medicaid |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
IP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
OP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem Medicaid |
$16.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Humana KY Medicaid |
$16.50
|
| Rate for Payer: Humana Medicare Advantage |
$9.17
|
| Rate for Payer: Kentucky WC Medicaid |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (300u SDV)
|
Professional
|
Both
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$28.79 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: Ambetter Exchange |
$9.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$9.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.17
|
| Rate for Payer: Multiplan PHCS |
$28.79
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.92
|
| Rate for Payer: UHCCP Medicaid |
$16.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.17
|
|
