|
ASPHERE HEAD 12/14 36 8.5
|
Facility
|
OP
|
$13,992.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,197.76 |
| Max. Negotiated Rate |
$13,432.83 |
| Rate for Payer: Aetna Commercial |
$10,774.25
|
| Rate for Payer: Anthem Medicaid |
$4,812.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,914.17
|
| Rate for Payer: Cash Price |
$6,996.26
|
| Rate for Payer: Cigna Commercial |
$11,613.80
|
| Rate for Payer: First Health Commercial |
$13,292.90
|
| Rate for Payer: Humana Commercial |
$11,893.65
|
| Rate for Payer: Humana KY Medicaid |
$4,812.03
|
| Rate for Payer: Kentucky WC Medicaid |
$4,861.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,473.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,326.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,197.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,908.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,313.43
|
| Rate for Payer: Ohio Health Group HMO |
$10,494.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,194.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,173.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,654.85
|
| Rate for Payer: PHCS Commercial |
$13,432.83
|
| Rate for Payer: United Healthcare All Payer |
$12,313.43
|
|
|
ASPHERE HEAD 12/14 36 8.5
|
Facility
|
IP
|
$13,992.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,197.76 |
| Max. Negotiated Rate |
$13,432.83 |
| Rate for Payer: Aetna Commercial |
$10,774.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,914.17
|
| Rate for Payer: Cash Price |
$6,996.26
|
| Rate for Payer: Cigna Commercial |
$11,613.80
|
| Rate for Payer: First Health Commercial |
$13,292.90
|
| Rate for Payer: Humana Commercial |
$11,893.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,473.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,326.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,197.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,313.43
|
| Rate for Payer: Ohio Health Group HMO |
$10,494.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,194.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,173.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,654.85
|
| Rate for Payer: PHCS Commercial |
$13,432.83
|
| Rate for Payer: United Healthcare All Payer |
$12,313.43
|
|
|
ASPHERE HEAD 12/14 40 1.5
|
Facility
|
OP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem Medicaid |
$6,562.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Humana KY Medicaid |
$6,562.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6,629.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,694.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 40 1.5
|
Facility
|
IP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 40 -2
|
Facility
|
OP
|
$18,252.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,475.84 |
| Max. Negotiated Rate |
$17,522.69 |
| Rate for Payer: Aetna Commercial |
$14,054.66
|
| Rate for Payer: Anthem Medicaid |
$6,277.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.18
|
| Rate for Payer: Cash Price |
$9,126.40
|
| Rate for Payer: Cigna Commercial |
$15,149.82
|
| Rate for Payer: First Health Commercial |
$17,340.16
|
| Rate for Payer: Humana Commercial |
$15,514.88
|
| Rate for Payer: Humana KY Medicaid |
$6,277.14
|
| Rate for Payer: Kentucky WC Medicaid |
$6,341.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,967.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,470.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,475.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,403.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,062.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,689.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,879.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,594.43
|
| Rate for Payer: PHCS Commercial |
$17,522.69
|
| Rate for Payer: United Healthcare All Payer |
$16,062.46
|
|
|
ASPHERE HEAD 12/14 40 -2
|
Facility
|
IP
|
$18,252.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,475.84 |
| Max. Negotiated Rate |
$17,522.69 |
| Rate for Payer: Aetna Commercial |
$14,054.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.18
|
| Rate for Payer: Cash Price |
$9,126.40
|
| Rate for Payer: Cigna Commercial |
$15,149.82
|
| Rate for Payer: First Health Commercial |
$17,340.16
|
| Rate for Payer: Humana Commercial |
$15,514.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,967.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,470.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,475.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,062.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,689.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,879.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,594.43
|
| Rate for Payer: PHCS Commercial |
$17,522.69
|
| Rate for Payer: United Healthcare All Payer |
$16,062.46
|
|
|
ASPHERE HEAD 12/14 40 5
|
Facility
|
OP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem Medicaid |
$6,562.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Humana KY Medicaid |
$6,562.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6,629.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,694.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 40 5
|
Facility
|
IP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 40 8.5
|
Facility
|
IP
|
$18,252.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,475.84 |
| Max. Negotiated Rate |
$17,522.69 |
| Rate for Payer: Aetna Commercial |
$14,054.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.18
|
| Rate for Payer: Cash Price |
$9,126.40
|
| Rate for Payer: Cigna Commercial |
$15,149.82
|
| Rate for Payer: First Health Commercial |
$17,340.16
|
| Rate for Payer: Humana Commercial |
$15,514.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,967.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,470.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,475.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,062.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,689.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,879.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,594.43
|
| Rate for Payer: PHCS Commercial |
$17,522.69
|
| Rate for Payer: United Healthcare All Payer |
$16,062.46
|
|
|
ASPHERE HEAD 12/14 40 8.5
|
Facility
|
OP
|
$18,252.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,475.84 |
| Max. Negotiated Rate |
$17,522.69 |
| Rate for Payer: Aetna Commercial |
$14,054.66
|
| Rate for Payer: Anthem Medicaid |
$6,277.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,237.18
|
| Rate for Payer: Cash Price |
$9,126.40
|
| Rate for Payer: Cigna Commercial |
$15,149.82
|
| Rate for Payer: First Health Commercial |
$17,340.16
|
| Rate for Payer: Humana Commercial |
$15,514.88
|
| Rate for Payer: Humana KY Medicaid |
$6,277.14
|
| Rate for Payer: Kentucky WC Medicaid |
$6,341.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,967.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,470.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,475.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,403.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,062.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,689.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,602.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,879.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,594.43
|
| Rate for Payer: PHCS Commercial |
$17,522.69
|
| Rate for Payer: United Healthcare All Payer |
$16,062.46
|
|
|
ASPHERE HEAD 12/14 44 1.5
|
Facility
|
OP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem Medicaid |
$6,562.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Humana KY Medicaid |
$6,562.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6,629.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,694.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 1.5
|
Facility
|
IP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 -2
|
Facility
|
OP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem Medicaid |
$6,562.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Humana KY Medicaid |
$6,562.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6,629.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,694.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 -2
|
Facility
|
IP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 5
|
Facility
|
IP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 5
|
Facility
|
OP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem Medicaid |
$6,562.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Humana KY Medicaid |
$6,562.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6,629.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,694.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 8.5
|
Facility
|
IP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
ASPHERE HEAD 12/14 44 8.5
|
Facility
|
OP
|
$19,083.97
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,725.19 |
| Max. Negotiated Rate |
$18,320.61 |
| Rate for Payer: Aetna Commercial |
$14,694.66
|
| Rate for Payer: Anthem Medicaid |
$6,562.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,885.50
|
| Rate for Payer: Cash Price |
$9,541.98
|
| Rate for Payer: Cigna Commercial |
$15,839.70
|
| Rate for Payer: First Health Commercial |
$18,129.77
|
| Rate for Payer: Humana Commercial |
$16,221.37
|
| Rate for Payer: Humana KY Medicaid |
$6,562.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6,629.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,648.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,083.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,725.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,694.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,793.89
|
| Rate for Payer: Ohio Health Group HMO |
$14,312.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,267.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,603.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,167.94
|
| Rate for Payer: PHCS Commercial |
$18,320.61
|
| Rate for Payer: United Healthcare All Payer |
$16,793.89
|
|
|
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 |
$88.35 |
| Max. Negotiated Rate |
$842.40 |
| Rate for Payer: Aetna Commercial |
$161.84
|
| Rate for Payer: Ambetter Exchange |
$88.35
|
| Rate for Payer: Anthem Medicaid |
$144.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$88.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$88.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.02
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$88.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.35
|
| 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 |
$114.86
|
| Rate for Payer: UHCCP Medicaid |
$491.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$145.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$88.35
|
|
|
ASP INJ RENAL CYST PELVIS
|
Facility
|
IP
|
$1,404.00
|
|
|
Service Code
|
HCPCS 50390
|
| Hospital Charge Code |
76102047
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.20 |
| Max. Negotiated Rate |
$1,347.84 |
| Rate for Payer: Aetna Commercial |
$1,081.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,095.12
|
| 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: 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 |
$421.20
|
| 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 |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,221.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$968.76
|
| Rate for Payer: PHCS Commercial |
$1,347.84
|
| Rate for Payer: United Healthcare All Payer |
$1,235.52
|
|
|
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 |
$482.84 |
| 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 |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,095.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| 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 |
$650.10
|
| 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 |
$780.12
|
| 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 |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,221.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$968.76
|
| Rate for Payer: PHCS Commercial |
$1,347.84
|
| Rate for Payer: United Healthcare All Payer |
$1,235.52
|
|
|
ASP INJ RENAL CYST PELVIS(P
|
Professional
|
Both
|
$530.00
|
|
|
Service Code
|
HCPCS 50390
|
| Hospital Charge Code |
761P2047
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.35 |
| Max. Negotiated Rate |
$318.00 |
| Rate for Payer: Aetna Commercial |
$161.84
|
| Rate for Payer: Ambetter Exchange |
$88.35
|
| Rate for Payer: Anthem Medicaid |
$144.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$88.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$88.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.02
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cash Price |
$265.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$88.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.93
|
| Rate for Payer: Molina Healthcare Passport |
$144.05
|
| Rate for Payer: Multiplan PHCS |
$318.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$114.86
|
| Rate for Payer: UHCCP Medicaid |
$185.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$145.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$88.35
|
|
|
ASP INJ RENAL CYST PELVIS(T
|
Facility
|
IP
|
$874.00
|
|
|
Service Code
|
HCPCS 50390
|
| Hospital Charge Code |
761T2047
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.20 |
| Max. Negotiated Rate |
$839.04 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$681.72
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cigna Commercial |
$725.42
|
| Rate for Payer: First Health Commercial |
$830.30
|
| Rate for Payer: Humana Commercial |
$742.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$716.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$769.12
|
| Rate for Payer: Ohio Health Group HMO |
$655.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$699.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.06
|
| Rate for Payer: PHCS Commercial |
$839.04
|
| Rate for Payer: United Healthcare All Payer |
$769.12
|
|
|
ASP INJ RENAL CYST PELVIS(T
|
Facility
|
OP
|
$874.00
|
|
|
Service Code
|
HCPCS 50390
|
| Hospital Charge Code |
761T2047
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.57 |
| Max. Negotiated Rate |
$910.14 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Anthem Medicaid |
$300.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$681.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cigna Commercial |
$725.42
|
| Rate for Payer: First Health Commercial |
$830.30
|
| Rate for Payer: Humana Commercial |
$742.90
|
| Rate for Payer: Humana KY Medicaid |
$300.57
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$303.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$716.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$306.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$769.12
|
| Rate for Payer: Ohio Health Group HMO |
$655.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$699.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.06
|
| Rate for Payer: PHCS Commercial |
$839.04
|
| Rate for Payer: United Healthcare All Payer |
$769.12
|
|
|
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION
|
Facility
|
OP
|
$381.85
|
|
|
Service Code
|
CPT 20612
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$272.75 |
| Max. Negotiated Rate |
$381.85 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
|
