|
SMART CONTROL ILIAC 6*20
|
Facility
|
OP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem Medicaid |
$2,537.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Humana KY Medicaid |
$2,537.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,563.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,588.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
SMART CONTROL ILIAC 6*20
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
SMART CONTROL ILIAC 6*30
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
SMART CONTROL ILIAC 6*30
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
SMART CONTROL ILIAC 6*60
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
SMART CONTROL ILIAC 6*60
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
SMART CONTROL ILIAC 7*80
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
SMART CONTROL ILIAC 7*80
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
SMART PORT CT LP CT66LTPD-VI
|
Facility
|
IP
|
$3,638.75
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.62 |
| Max. Negotiated Rate |
$3,493.20 |
| Rate for Payer: Aetna Commercial |
$2,801.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,838.22
|
| Rate for Payer: Cash Price |
$1,819.38
|
| Rate for Payer: Cigna Commercial |
$3,020.16
|
| Rate for Payer: First Health Commercial |
$3,456.81
|
| Rate for Payer: Humana Commercial |
$3,092.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,983.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,685.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,091.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,202.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,729.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,911.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,165.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,510.74
|
| Rate for Payer: PHCS Commercial |
$3,493.20
|
| Rate for Payer: United Healthcare All Payer |
$3,202.10
|
|
|
SMART PORT CT LP CT66LTPD-VI
|
Facility
|
OP
|
$3,638.75
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,091.62 |
| Max. Negotiated Rate |
$3,493.20 |
| Rate for Payer: Aetna Commercial |
$2,801.84
|
| Rate for Payer: Anthem Medicaid |
$1,251.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,838.22
|
| Rate for Payer: Cash Price |
$1,819.38
|
| Rate for Payer: Cigna Commercial |
$3,020.16
|
| Rate for Payer: First Health Commercial |
$3,456.81
|
| Rate for Payer: Humana Commercial |
$3,092.94
|
| Rate for Payer: Humana KY Medicaid |
$1,251.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,264.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,983.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,685.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,091.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,276.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,202.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,729.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,911.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,165.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,510.74
|
| Rate for Payer: PHCS Commercial |
$3,493.20
|
| Rate for Payer: United Healthcare All Payer |
$3,202.10
|
|
|
SMART TOE ANGLED 16MM
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE ANGLED 16MM
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE ANGLED 19MM
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE ANGLED 19MM
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE DIP IMPLANT 11MM
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE DIP IMPLANT 11MM
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE DIP IMPLANT 13MM
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
SMART TOE DIP IMPLANT 13MM
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
SMART TOE STRAIGHT 16MM
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE STRAIGHT 16MM
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE STRAIGHT 19MM
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMART TOE STRAIGHT 19MM
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
SMEAR KOH PREP
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
30001337
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$5.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$5.82
|
| Rate for Payer: Humana Medicare Advantage |
$5.82
|
| Rate for Payer: Kentucky WC Medicaid |
$5.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
SMEAR KOH PREP
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
30001337
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
SM INT ENDSCPYENTRSCPY SECPRTN
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 44373
|
| Hospital Charge Code |
761P1847
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$314.37 |
| Rate for Payer: Aetna Commercial |
$314.37
|
| Rate for Payer: Ambetter Exchange |
$179.58
|
| Rate for Payer: Anthem Medicaid |
$262.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$179.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$179.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$215.50
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$283.40
|
| Rate for Payer: Healthspan PPO |
$265.11
|
| Rate for Payer: Humana Medicaid |
$262.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$179.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$179.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$267.93
|
| Rate for Payer: Molina Healthcare Passport |
$262.68
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$233.45
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$265.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$179.58
|
|
