|
ASPHERE HEAD 12/14 36 1.5
|
Facility
|
IP
|
$12,856.43
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,671.34 |
| Max. Negotiated Rate |
$12,342.17 |
| Rate for Payer: Aetna Commercial |
$9,899.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,028.02
|
| Rate for Payer: Cash Price |
$6,428.22
|
| Rate for Payer: Cigna Commercial |
$10,670.84
|
| Rate for Payer: First Health Commercial |
$12,213.61
|
| Rate for Payer: Humana Commercial |
$10,927.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,542.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,488.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,856.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,313.66
|
| Rate for Payer: Ohio Health Group HMO |
$9,642.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,571.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,671.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,985.49
|
| Rate for Payer: PHCS Commercial |
$12,342.17
|
| Rate for Payer: United Healthcare All Payer |
$11,313.66
|
|
|
ASPHERE HEAD 12/14 36 -2
|
Facility
|
IP
|
$13,238.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,721.06 |
| Max. Negotiated Rate |
$12,709.39 |
| Rate for Payer: Aetna Commercial |
$10,193.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,326.38
|
| Rate for Payer: Cash Price |
$6,619.48
|
| Rate for Payer: Cigna Commercial |
$10,988.33
|
| Rate for Payer: First Health Commercial |
$12,577.00
|
| Rate for Payer: Humana Commercial |
$11,253.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,855.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,770.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,971.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,650.28
|
| Rate for Payer: Ohio Health Group HMO |
$9,929.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,647.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,721.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,104.07
|
| Rate for Payer: PHCS Commercial |
$12,709.39
|
| Rate for Payer: United Healthcare All Payer |
$11,650.28
|
|
|
ASPHERE HEAD 12/14 36 -2
|
Facility
|
OP
|
$13,238.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,721.06 |
| Max. Negotiated Rate |
$12,709.39 |
| Rate for Payer: Aetna Commercial |
$10,193.99
|
| Rate for Payer: Anthem Medicaid |
$4,552.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,326.38
|
| Rate for Payer: Cash Price |
$6,619.48
|
| Rate for Payer: Cigna Commercial |
$10,988.33
|
| Rate for Payer: First Health Commercial |
$12,577.00
|
| Rate for Payer: Humana Commercial |
$11,253.11
|
| Rate for Payer: Humana KY Medicaid |
$4,552.87
|
| Rate for Payer: Kentucky WC Medicaid |
$4,599.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,855.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,770.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,971.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,644.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,650.28
|
| Rate for Payer: Ohio Health Group HMO |
$9,929.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,647.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,721.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,104.07
|
| Rate for Payer: PHCS Commercial |
$12,709.39
|
| Rate for Payer: United Healthcare All Payer |
$11,650.28
|
|
|
ASPHERE HEAD 12/14 36 5
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 36 5
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 36 8.5
|
Facility
|
OP
|
$13,735.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,785.60 |
| Max. Negotiated Rate |
$13,185.94 |
| Rate for Payer: Aetna Commercial |
$10,576.22
|
| Rate for Payer: Anthem Medicaid |
$4,723.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,713.57
|
| Rate for Payer: Cash Price |
$6,867.68
|
| Rate for Payer: Cigna Commercial |
$11,400.34
|
| Rate for Payer: First Health Commercial |
$13,048.58
|
| Rate for Payer: Humana Commercial |
$11,675.05
|
| Rate for Payer: Humana KY Medicaid |
$4,723.59
|
| Rate for Payer: Kentucky WC Medicaid |
$4,771.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,262.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,136.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,120.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,818.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,087.11
|
| Rate for Payer: Ohio Health Group HMO |
$10,301.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,747.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,785.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,257.96
|
| Rate for Payer: PHCS Commercial |
$13,185.94
|
| Rate for Payer: United Healthcare All Payer |
$12,087.11
|
|
|
ASPHERE HEAD 12/14 36 8.5
|
Facility
|
IP
|
$13,735.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,785.60 |
| Max. Negotiated Rate |
$13,185.94 |
| Rate for Payer: Aetna Commercial |
$10,576.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,713.57
|
| Rate for Payer: Cash Price |
$6,867.68
|
| Rate for Payer: Cigna Commercial |
$11,400.34
|
| Rate for Payer: First Health Commercial |
$13,048.58
|
| Rate for Payer: Humana Commercial |
$11,675.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,262.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,136.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,120.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,087.11
|
| Rate for Payer: Ohio Health Group HMO |
$10,301.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,747.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,785.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,257.96
|
| Rate for Payer: PHCS Commercial |
$13,185.94
|
| Rate for Payer: United Healthcare All Payer |
$12,087.11
|
|
|
ASPHERE HEAD 12/14 40 1.5
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 40 1.5
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 40 -2
|
Facility
|
OP
|
$17,678.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.19 |
| Max. Negotiated Rate |
$16,971.26 |
| Rate for Payer: Aetna Commercial |
$13,612.37
|
| Rate for Payer: Anthem Medicaid |
$6,079.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.15
|
| Rate for Payer: Cash Price |
$8,839.20
|
| Rate for Payer: Cigna Commercial |
$14,673.07
|
| Rate for Payer: First Health Commercial |
$16,794.48
|
| Rate for Payer: Humana Commercial |
$15,026.64
|
| Rate for Payer: Humana KY Medicaid |
$6,079.60
|
| Rate for Payer: Kentucky WC Medicaid |
$6,141.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,496.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,046.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,201.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,556.99
|
| Rate for Payer: Ohio Health Group HMO |
$13,258.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.30
|
| Rate for Payer: PHCS Commercial |
$16,971.26
|
| Rate for Payer: United Healthcare All Payer |
$15,556.99
|
|
|
ASPHERE HEAD 12/14 40 -2
|
Facility
|
IP
|
$17,678.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.19 |
| Max. Negotiated Rate |
$16,971.26 |
| Rate for Payer: Aetna Commercial |
$13,612.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.15
|
| Rate for Payer: Cash Price |
$8,839.20
|
| Rate for Payer: Cigna Commercial |
$14,673.07
|
| Rate for Payer: First Health Commercial |
$16,794.48
|
| Rate for Payer: Humana Commercial |
$15,026.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,496.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,046.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,556.99
|
| Rate for Payer: Ohio Health Group HMO |
$13,258.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.30
|
| Rate for Payer: PHCS Commercial |
$16,971.26
|
| Rate for Payer: United Healthcare All Payer |
$15,556.99
|
|
|
ASPHERE HEAD 12/14 40 5
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 40 5
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 40 8.5
|
Facility
|
OP
|
$17,678.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.19 |
| Max. Negotiated Rate |
$16,971.26 |
| Rate for Payer: Aetna Commercial |
$13,612.37
|
| Rate for Payer: Anthem Medicaid |
$6,079.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.15
|
| Rate for Payer: Cash Price |
$8,839.20
|
| Rate for Payer: Cigna Commercial |
$14,673.07
|
| Rate for Payer: First Health Commercial |
$16,794.48
|
| Rate for Payer: Humana Commercial |
$15,026.64
|
| Rate for Payer: Humana KY Medicaid |
$6,079.60
|
| Rate for Payer: Kentucky WC Medicaid |
$6,141.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,496.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,046.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,201.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,556.99
|
| Rate for Payer: Ohio Health Group HMO |
$13,258.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.30
|
| Rate for Payer: PHCS Commercial |
$16,971.26
|
| Rate for Payer: United Healthcare All Payer |
$15,556.99
|
|
|
ASPHERE HEAD 12/14 40 8.5
|
Facility
|
IP
|
$17,678.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.19 |
| Max. Negotiated Rate |
$16,971.26 |
| Rate for Payer: Aetna Commercial |
$13,612.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.15
|
| Rate for Payer: Cash Price |
$8,839.20
|
| Rate for Payer: Cigna Commercial |
$14,673.07
|
| Rate for Payer: First Health Commercial |
$16,794.48
|
| Rate for Payer: Humana Commercial |
$15,026.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,496.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,046.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,556.99
|
| Rate for Payer: Ohio Health Group HMO |
$13,258.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.30
|
| Rate for Payer: PHCS Commercial |
$16,971.26
|
| Rate for Payer: United Healthcare All Payer |
$15,556.99
|
|
|
ASPHERE HEAD 12/14 44 1.5
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 1.5
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 -2
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 -2
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 5
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 5
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 8.5
|
Facility
|
OP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem Medicaid |
$6,357.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Humana KY Medicaid |
$6,357.71
|
| Rate for Payer: Kentucky WC Medicaid |
$6,422.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASPHERE HEAD 12/14 44 8.5
|
Facility
|
IP
|
$18,487.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,403.32 |
| Max. Negotiated Rate |
$17,747.62 |
| Rate for Payer: Aetna Commercial |
$14,235.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,419.94
|
| Rate for Payer: Cash Price |
$9,243.55
|
| Rate for Payer: Cigna Commercial |
$15,344.29
|
| Rate for Payer: First Health Commercial |
$17,562.74
|
| Rate for Payer: Humana Commercial |
$15,714.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,159.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,643.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,546.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,268.65
|
| Rate for Payer: Ohio Health Group HMO |
$13,865.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,403.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.00
|
| Rate for Payer: PHCS Commercial |
$17,747.62
|
| Rate for Payer: United Healthcare All Payer |
$16,268.65
|
|
|
ASP INJ RENAL CYST PELVIS
|
Facility
|
OP
|
$1,404.00
|
|
|
Service Code
|
HCPCS 50390
|
| Hospital Charge Code |
76102047
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.52 |
| Max. Negotiated Rate |
$1,347.84 |
| Rate for Payer: Aetna Commercial |
$1,081.08
|
| Rate for Payer: Anthem Medicaid |
$482.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,095.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cigna Commercial |
$1,165.32
|
| Rate for Payer: First Health Commercial |
$1,333.80
|
| Rate for Payer: Humana Commercial |
$1,193.40
|
| Rate for Payer: Humana KY Medicaid |
$482.84
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$487.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,151.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,036.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$492.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,235.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,053.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$182.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$435.24
|
| Rate for Payer: PHCS Commercial |
$1,347.84
|
| Rate for Payer: United Healthcare All Payer |
$1,235.52
|
|
|
ASP INJ RENAL CYST PELVIS
|
Professional
|
Both
|
$1,404.00
|
|
|
Service Code
|
HCPCS 50390
|
| Hospital Charge Code |
76102047
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.41 |
| Max. Negotiated Rate |
$1,404.00 |
| Rate for Payer: Aetna Commercial |
$161.84
|
| Rate for Payer: Anthem Medicaid |
$144.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,404.00
|
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cigna Commercial |
$144.90
|
| Rate for Payer: Healthspan PPO |
$129.41
|
| Rate for Payer: Humana Medicaid |
$144.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$132.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.93
|
| Rate for Payer: Molina Healthcare Passport |
$144.05
|
| Rate for Payer: Multiplan PHCS |
$842.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$982.80
|
| Rate for Payer: UHCCP Medicaid |
$491.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$145.49
|
|
