Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL

Facility

$1,103.49

Service Code	CPT 64483
Hospital Revenue Code	360
Min. Negotiated Rate	$788.21
Max. Negotiated Rate	$1,103.49
Rate for Payer: Anthem Medicare Advantage/PPO	$788.21
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,103.49
Rate for Payer: CareSource Just4Me Medicare	$1,064.08
Rate for Payer: Humana Medicare Advantage	$788.21
Rate for Payer: Molina Healthcare Benefit Exchange	$945.85

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

Facility

$1,103.49

Service Code	CPT 64490
Hospital Revenue Code	360
Min. Negotiated Rate	$788.21
Max. Negotiated Rate	$1,103.49
Rate for Payer: Anthem Medicare Advantage/PPO	$788.21
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,103.49
Rate for Payer: CareSource Just4Me Medicare	$1,064.08
Rate for Payer: Humana Medicare Advantage	$788.21
Rate for Payer: Molina Healthcare Benefit Exchange	$945.85

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

Facility

$1,103.49

Service Code	CPT 64493
Hospital Revenue Code	360
Min. Negotiated Rate	$788.21
Max. Negotiated Rate	$1,103.49
Rate for Payer: Anthem Medicare Advantage/PPO	$788.21
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,103.49
Rate for Payer: CareSource Just4Me Medicare	$1,064.08
Rate for Payer: Humana Medicare Advantage	$788.21
Rate for Payer: Molina Healthcare Benefit Exchange	$945.85

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)

Facility

$837.23

Service Code	CPT 62321
Hospital Revenue Code	360
Min. Negotiated Rate	$598.02
Max. Negotiated Rate	$837.23
Rate for Payer: Anthem Medicare Advantage/PPO	$598.02
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$837.23
Rate for Payer: CareSource Just4Me Medicare	$807.33
Rate for Payer: Humana Medicare Advantage	$598.02
Rate for Payer: Molina Healthcare Benefit Exchange	$717.62

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)

Facility

$837.23

Service Code	CPT 62323
Hospital Revenue Code	360
Min. Negotiated Rate	$598.02
Max. Negotiated Rate	$837.23
Rate for Payer: Anthem Medicare Advantage/PPO	$598.02
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$837.23
Rate for Payer: CareSource Just4Me Medicare	$807.33
Rate for Payer: Humana Medicare Advantage	$598.02
Rate for Payer: Molina Healthcare Benefit Exchange	$717.62

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE

Facility

$1,103.49

Service Code	CPT 62322
Hospital Revenue Code	360
Min. Negotiated Rate	$788.21
Max. Negotiated Rate	$1,103.49
Rate for Payer: Anthem Medicare Advantage/PPO	$788.21
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,103.49
Rate for Payer: CareSource Just4Me Medicare	$1,064.08
Rate for Payer: Humana Medicare Advantage	$788.21
Rate for Payer: Molina Healthcare Benefit Exchange	$945.85

INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)

Facility

$358.57

Service Code	CPT 20552
Hospital Revenue Code	360
Min. Negotiated Rate	$256.12
Max. Negotiated Rate	$358.57
Rate for Payer: Anthem Medicare Advantage/PPO	$256.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$358.57
Rate for Payer: CareSource Just4Me Medicare	$345.76
Rate for Payer: Humana Medicare Advantage	$256.12
Rate for Payer: Molina Healthcare Benefit Exchange	$307.34

INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES

Facility

$358.57

Service Code	CPT 20553
Hospital Revenue Code	360
Min. Negotiated Rate	$256.12
Max. Negotiated Rate	$358.57
Rate for Payer: Anthem Medicare Advantage/PPO	$256.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$358.57
Rate for Payer: CareSource Just4Me Medicare	$345.76
Rate for Payer: Humana Medicare Advantage	$256.12
Rate for Payer: Molina Healthcare Benefit Exchange	$307.34

INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR "FASCIA")

Facility

$358.57

Service Code	CPT 20550
Hospital Revenue Code	360
Min. Negotiated Rate	$256.12
Max. Negotiated Rate	$358.57
Rate for Payer: Anthem Medicare Advantage/PPO	$256.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$358.57
Rate for Payer: CareSource Just4Me Medicare	$345.76
Rate for Payer: Humana Medicare Advantage	$256.12
Rate for Payer: Molina Healthcare Benefit Exchange	$307.34

INJECTION TREATMENT OF NERVE

Professional

Both

$3,340.00

Service Code	HCPCS 64681
Hospital Charge Code	76102819
Hospital Revenue Code	761
Min. Negotiated Rate	$114.03
Max. Negotiated Rate	$3,340.00
Rate for Payer: Aetna Commercial	$345.69
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$114.03
Rate for Payer: Anthem Medicaid	$160.99
Rate for Payer: Buckeye Medicare Advantage	$3,340.00
Rate for Payer: Cash Price	$1,670.00
Rate for Payer: Cash Price	$1,670.00
Rate for Payer: Cigna Commercial	$333.63
Rate for Payer: Healthspan PPO	$471.66
Rate for Payer: Humana Medicaid	$160.99
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$254.09
Rate for Payer: Molina Healthcare CHIP/Medicaid	$164.21
Rate for Payer: Molina Healthcare Passport	$160.99
Rate for Payer: Multiplan PHCS	$2,004.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,338.00
Rate for Payer: UHCCP Medicaid	$119.73
Rate for Payer: Wellcare CHIP/Medicaid	$162.60

INJECTION TREATMENT OF NERVE

Facility

$3,340.00

Service Code	HCPCS 64681
Hospital Charge Code	76102819
Hospital Revenue Code	761
Min. Negotiated Rate	$434.20
Max. Negotiated Rate	$3,206.40
Rate for Payer: Aetna Commercial	$2,571.80
Rate for Payer: Anthem POS/PPO/Traditional	$2,605.20
Rate for Payer: Cash Price	$1,670.00
Rate for Payer: Cigna Commercial	$2,772.20
Rate for Payer: First Health Commercial	$3,173.00
Rate for Payer: Humana Commercial	$2,839.00
Rate for Payer: Medical Mutual Of Ohio HMO	$2,738.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,464.92
Rate for Payer: Molina Healthcare Benefit Exchange	$1,002.00
Rate for Payer: Ohio Health Choice Commercial	$2,939.20
Rate for Payer: Ohio Health Group HMO	$2,505.00
Rate for Payer: Ohio Health Group PPO Differential	$668.00
Rate for Payer: Ohio Health Group PPO No Differential	$434.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,035.40
Rate for Payer: PHCS Commercial	$3,206.40
Rate for Payer: United Healthcare All Payer	$2,939.20

INJECTION TREATMENT OF NERVE

Facility

$3,340.00

Service Code	HCPCS 64681
Hospital Charge Code	76102819
Hospital Revenue Code	761
Min. Negotiated Rate	$434.20
Max. Negotiated Rate	$3,206.40
Rate for Payer: Aetna Commercial	$2,571.80
Rate for Payer: Anthem Medicaid	$1,148.63
Rate for Payer: Anthem Medicare Advantage/PPO	$788.21
Rate for Payer: Anthem POS/PPO/Traditional	$2,605.20
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,103.49
Rate for Payer: CareSource Just4Me Medicare	$1,064.08
Rate for Payer: Cash Price	$1,670.00
Rate for Payer: Cash Price	$1,670.00
Rate for Payer: Cigna Commercial	$2,772.20
Rate for Payer: First Health Commercial	$3,173.00
Rate for Payer: Humana Commercial	$2,839.00
Rate for Payer: Humana KY Medicaid	$1,148.63
Rate for Payer: Humana Medicare Advantage	$788.21
Rate for Payer: Kentucky WC Medicaid	$1,160.32
Rate for Payer: Medical Mutual Of Ohio HMO	$2,738.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,464.92
Rate for Payer: Molina Healthcare Benefit Exchange	$945.85
Rate for Payer: Molina Healthcare Medicaid	$1,171.67
Rate for Payer: Ohio Health Choice Commercial	$2,939.20
Rate for Payer: Ohio Health Group HMO	$2,505.00
Rate for Payer: Ohio Health Group PPO Differential	$668.00
Rate for Payer: Ohio Health Group PPO No Differential	$434.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,035.40
Rate for Payer: PHCS Commercial	$3,206.40
Rate for Payer: United Healthcare All Payer	$2,939.20

INJECTION TREATMENT OF NERVE(P

Professional

Both

$485.00

Service Code	HCPCS 64681
Hospital Charge Code	761P2819
Hospital Revenue Code	761
Min. Negotiated Rate	$114.03
Max. Negotiated Rate	$485.00
Rate for Payer: Aetna Commercial	$345.69
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$114.03
Rate for Payer: Anthem Medicaid	$160.99
Rate for Payer: Buckeye Medicare Advantage	$485.00
Rate for Payer: Cash Price	$242.50
Rate for Payer: Cash Price	$242.50
Rate for Payer: Cigna Commercial	$333.63
Rate for Payer: Healthspan PPO	$471.66
Rate for Payer: Humana Medicaid	$160.99
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$254.09
Rate for Payer: Molina Healthcare CHIP/Medicaid	$164.21
Rate for Payer: Molina Healthcare Passport	$160.99
Rate for Payer: Multiplan PHCS	$291.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$339.50
Rate for Payer: UHCCP Medicaid	$119.73
Rate for Payer: Wellcare CHIP/Medicaid	$162.60

INJECTION TREATMENT OF NERVE(T

Facility

$2,855.00

Service Code	HCPCS 64681
Hospital Charge Code	761T2819
Hospital Revenue Code	761
Min. Negotiated Rate	$371.15
Max. Negotiated Rate	$2,740.80
Rate for Payer: Aetna Commercial	$2,198.35
Rate for Payer: Anthem POS/PPO/Traditional	$2,226.90
Rate for Payer: Cash Price	$1,427.50
Rate for Payer: Cigna Commercial	$2,369.65
Rate for Payer: First Health Commercial	$2,712.25
Rate for Payer: Humana Commercial	$2,426.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,341.10
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,106.99
Rate for Payer: Molina Healthcare Benefit Exchange	$856.50
Rate for Payer: Ohio Health Choice Commercial	$2,512.40
Rate for Payer: Ohio Health Group HMO	$2,141.25
Rate for Payer: Ohio Health Group PPO Differential	$571.00
Rate for Payer: Ohio Health Group PPO No Differential	$371.15
Rate for Payer: Ohio Health Group PPO SOMC Employees	$885.05
Rate for Payer: PHCS Commercial	$2,740.80
Rate for Payer: United Healthcare All Payer	$2,512.40

INJECTION TREATMENT OF NERVE(T

Facility

$2,855.00

Service Code	HCPCS 64681
Hospital Charge Code	761T2819
Hospital Revenue Code	761
Min. Negotiated Rate	$371.15
Max. Negotiated Rate	$2,740.80
Rate for Payer: Aetna Commercial	$2,198.35
Rate for Payer: Anthem Medicaid	$981.83
Rate for Payer: Anthem Medicare Advantage/PPO	$788.21
Rate for Payer: Anthem POS/PPO/Traditional	$2,226.90
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,103.49
Rate for Payer: CareSource Just4Me Medicare	$1,064.08
Rate for Payer: Cash Price	$1,427.50
Rate for Payer: Cash Price	$1,427.50
Rate for Payer: Cigna Commercial	$2,369.65
Rate for Payer: First Health Commercial	$2,712.25
Rate for Payer: Humana Commercial	$2,426.75
Rate for Payer: Humana KY Medicaid	$981.83
Rate for Payer: Humana Medicare Advantage	$788.21
Rate for Payer: Kentucky WC Medicaid	$991.83
Rate for Payer: Medical Mutual Of Ohio HMO	$2,341.10
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,106.99
Rate for Payer: Molina Healthcare Benefit Exchange	$945.85
Rate for Payer: Molina Healthcare Medicaid	$1,001.53
Rate for Payer: Ohio Health Choice Commercial	$2,512.40
Rate for Payer: Ohio Health Group HMO	$2,141.25
Rate for Payer: Ohio Health Group PPO Differential	$571.00
Rate for Payer: Ohio Health Group PPO No Differential	$371.15
Rate for Payer: Ohio Health Group PPO SOMC Employees	$885.05
Rate for Payer: PHCS Commercial	$2,740.80
Rate for Payer: United Healthcare All Payer	$2,512.40

INJECTOR NEEDLE KIT 4MM*27G

Facility

$1,101.59

Hospital Charge Code	27000242
Hospital Revenue Code	272
Min. Negotiated Rate	$143.21
Max. Negotiated Rate	$1,057.53
Rate for Payer: Aetna Commercial	$848.22
Rate for Payer: Anthem Medicaid	$378.84
Rate for Payer: Anthem POS/PPO/Traditional	$859.24
Rate for Payer: Cash Price	$550.80
Rate for Payer: Cigna Commercial	$914.32
Rate for Payer: First Health Commercial	$1,046.51
Rate for Payer: Humana Commercial	$936.35
Rate for Payer: Humana KY Medicaid	$378.84
Rate for Payer: Kentucky WC Medicaid	$382.69
Rate for Payer: Medical Mutual Of Ohio HMO	$903.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$812.97
Rate for Payer: Molina Healthcare Benefit Exchange	$330.48
Rate for Payer: Molina Healthcare Medicaid	$386.44
Rate for Payer: Ohio Health Choice Commercial	$969.40
Rate for Payer: Ohio Health Group HMO	$826.19
Rate for Payer: Ohio Health Group PPO Differential	$220.32
Rate for Payer: Ohio Health Group PPO No Differential	$143.21
Rate for Payer: Ohio Health Group PPO SOMC Employees	$341.49
Rate for Payer: PHCS Commercial	$1,057.53
Rate for Payer: United Healthcare All Payer	$969.40

INJECTOR NEEDLE KIT 4MM*27G

Facility

$1,101.59

Hospital Charge Code	27000242
Hospital Revenue Code	272
Min. Negotiated Rate	$143.21
Max. Negotiated Rate	$1,057.53
Rate for Payer: Aetna Commercial	$848.22
Rate for Payer: Anthem POS/PPO/Traditional	$859.24
Rate for Payer: Cash Price	$550.80
Rate for Payer: Cigna Commercial	$914.32
Rate for Payer: First Health Commercial	$1,046.51
Rate for Payer: Humana Commercial	$936.35
Rate for Payer: Medical Mutual Of Ohio HMO	$903.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$812.97
Rate for Payer: Molina Healthcare Benefit Exchange	$330.48
Rate for Payer: Ohio Health Choice Commercial	$969.40
Rate for Payer: Ohio Health Group HMO	$826.19
Rate for Payer: Ohio Health Group PPO Differential	$220.32
Rate for Payer: Ohio Health Group PPO No Differential	$143.21
Rate for Payer: Ohio Health Group PPO SOMC Employees	$341.49
Rate for Payer: PHCS Commercial	$1,057.53
Rate for Payer: United Healthcare All Payer	$969.40

INJECT.PROCEDURE - ABD.SHUNT

Professional

Both

$1,197.00

Service Code	HCPCS 49427
Hospital Charge Code	76102003
Hospital Revenue Code	761
Min. Negotiated Rate	$39.99
Max. Negotiated Rate	$1,197.00
Rate for Payer: Aetna Commercial	$74.57
Rate for Payer: Anthem Medicaid	$39.99
Rate for Payer: Buckeye Medicare Advantage	$1,197.00
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$67.20
Rate for Payer: Healthspan PPO	$62.88
Rate for Payer: Humana Medicaid	$39.99
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$59.76
Rate for Payer: Molina Healthcare CHIP/Medicaid	$40.79
Rate for Payer: Molina Healthcare Passport	$39.99
Rate for Payer: Multiplan PHCS	$718.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$837.90
Rate for Payer: UHCCP Medicaid	$418.95
Rate for Payer: Wellcare CHIP/Medicaid	$40.39

INJECT.PROCEDURE - ABD.SHUNT

Facility

$1,197.00

Service Code	HCPCS 49427
Hospital Charge Code	76102003
Hospital Revenue Code	761
Min. Negotiated Rate	$155.61
Max. Negotiated Rate	$1,149.12
Rate for Payer: Aetna Commercial	$921.69
Rate for Payer: Anthem POS/PPO/Traditional	$933.66
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$993.51
Rate for Payer: First Health Commercial	$1,137.15
Rate for Payer: Humana Commercial	$1,017.45
Rate for Payer: Medical Mutual Of Ohio HMO	$981.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$883.39
Rate for Payer: Molina Healthcare Benefit Exchange	$359.10
Rate for Payer: Ohio Health Choice Commercial	$1,053.36
Rate for Payer: Ohio Health Group HMO	$897.75
Rate for Payer: Ohio Health Group PPO Differential	$239.40
Rate for Payer: Ohio Health Group PPO No Differential	$155.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$371.07
Rate for Payer: PHCS Commercial	$1,149.12
Rate for Payer: United Healthcare All Payer	$1,053.36

INJECT.PROCEDURE - ABD.SHUNT

Facility

$1,197.00

Service Code	HCPCS 49427
Hospital Charge Code	76102003
Hospital Revenue Code	761
Min. Negotiated Rate	$155.61
Max. Negotiated Rate	$1,149.12
Rate for Payer: Aetna Commercial	$921.69
Rate for Payer: Anthem Medicaid	$411.65
Rate for Payer: Anthem POS/PPO/Traditional	$933.66
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$993.51
Rate for Payer: First Health Commercial	$1,137.15
Rate for Payer: Humana Commercial	$1,017.45
Rate for Payer: Humana KY Medicaid	$411.65
Rate for Payer: Kentucky WC Medicaid	$415.84
Rate for Payer: Medical Mutual Of Ohio HMO	$981.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$883.39
Rate for Payer: Molina Healthcare Benefit Exchange	$359.10
Rate for Payer: Molina Healthcare Medicaid	$419.91
Rate for Payer: Ohio Health Choice Commercial	$1,053.36
Rate for Payer: Ohio Health Group HMO	$897.75
Rate for Payer: Ohio Health Group PPO Differential	$239.40
Rate for Payer: Ohio Health Group PPO No Differential	$155.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$371.07
Rate for Payer: PHCS Commercial	$1,149.12
Rate for Payer: United Healthcare All Payer	$1,053.36

INJECT.PROCEDURE - ABD.SHUNT(P

Professional

Both

$400.00

Service Code	HCPCS 49427
Hospital Charge Code	761P2003
Hospital Revenue Code	761
Min. Negotiated Rate	$39.99
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$74.57
Rate for Payer: Anthem Medicaid	$39.99
Rate for Payer: Buckeye Medicare Advantage	$400.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cigna Commercial	$67.20
Rate for Payer: Healthspan PPO	$62.88
Rate for Payer: Humana Medicaid	$39.99
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$59.76
Rate for Payer: Molina Healthcare CHIP/Medicaid	$40.79
Rate for Payer: Molina Healthcare Passport	$39.99
Rate for Payer: Multiplan PHCS	$240.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$280.00
Rate for Payer: UHCCP Medicaid	$140.00
Rate for Payer: Wellcare CHIP/Medicaid	$40.39

INJECT.PROCEDURE - ABD.SHUNT(T

Facility

$797.00

Service Code	HCPCS 49427
Hospital Charge Code	761T2003
Hospital Revenue Code	761
Min. Negotiated Rate	$103.61
Max. Negotiated Rate	$765.12
Rate for Payer: Aetna Commercial	$613.69
Rate for Payer: Anthem POS/PPO/Traditional	$621.66
Rate for Payer: Cash Price	$398.50
Rate for Payer: Cigna Commercial	$661.51
Rate for Payer: First Health Commercial	$757.15
Rate for Payer: Humana Commercial	$677.45
Rate for Payer: Medical Mutual Of Ohio HMO	$653.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$588.19
Rate for Payer: Molina Healthcare Benefit Exchange	$239.10
Rate for Payer: Ohio Health Choice Commercial	$701.36
Rate for Payer: Ohio Health Group HMO	$597.75
Rate for Payer: Ohio Health Group PPO Differential	$159.40
Rate for Payer: Ohio Health Group PPO No Differential	$103.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$247.07
Rate for Payer: PHCS Commercial	$765.12
Rate for Payer: United Healthcare All Payer	$701.36

INJECT.PROCEDURE - ABD.SHUNT(T

Facility

$797.00

Service Code	HCPCS 49427
Hospital Charge Code	761T2003
Hospital Revenue Code	761
Min. Negotiated Rate	$103.61
Max. Negotiated Rate	$765.12
Rate for Payer: Aetna Commercial	$613.69
Rate for Payer: Anthem Medicaid	$274.09
Rate for Payer: Anthem POS/PPO/Traditional	$621.66
Rate for Payer: Cash Price	$398.50
Rate for Payer: Cigna Commercial	$661.51
Rate for Payer: First Health Commercial	$757.15
Rate for Payer: Humana Commercial	$677.45
Rate for Payer: Humana KY Medicaid	$274.09
Rate for Payer: Kentucky WC Medicaid	$276.88
Rate for Payer: Medical Mutual Of Ohio HMO	$653.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$588.19
Rate for Payer: Molina Healthcare Benefit Exchange	$239.10
Rate for Payer: Molina Healthcare Medicaid	$279.59
Rate for Payer: Ohio Health Choice Commercial	$701.36
Rate for Payer: Ohio Health Group HMO	$597.75
Rate for Payer: Ohio Health Group PPO Differential	$159.40
Rate for Payer: Ohio Health Group PPO No Differential	$103.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$247.07
Rate for Payer: PHCS Commercial	$765.12
Rate for Payer: United Healthcare All Payer	$701.36

INJECT PULM ART HRT CATH

Professional

Both

$2,516.00

Service Code	HCPCS 93568
Hospital Charge Code	76102491
Hospital Revenue Code	761
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$2,516.00
Rate for Payer: Aetna Commercial	$70.98
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$24.23
Rate for Payer: Anthem Medicaid	$38.57
Rate for Payer: Buckeye Medicare Advantage	$2,516.00
Rate for Payer: Cash Price	$1,258.00
Rate for Payer: Cash Price	$1,258.00
Rate for Payer: Cigna Commercial	$78.50
Rate for Payer: Healthspan PPO	$177.26
Rate for Payer: Humana Medicaid	$38.57
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$59.09
Rate for Payer: Molina Healthcare CHIP/Medicaid	$39.34
Rate for Payer: Molina Healthcare Passport	$38.57
Rate for Payer: Multiplan PHCS	$1,509.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,761.20
Rate for Payer: UHCCP Medicaid	$25.44
Rate for Payer: Wellcare CHIP/Medicaid	$38.96

INJECT PULM ART HRT CATH

Facility

$2,166.00

Service Code	HCPCS 93568
Hospital Charge Code	48100078
Hospital Revenue Code	481
Min. Negotiated Rate	$281.58
Max. Negotiated Rate	$2,079.36
Rate for Payer: Aetna Commercial	$1,667.82
Rate for Payer: Anthem POS/PPO/Traditional	$1,689.48
Rate for Payer: Cash Price	$1,083.00
Rate for Payer: Cigna Commercial	$1,797.78
Rate for Payer: First Health Commercial	$2,057.70
Rate for Payer: Humana Commercial	$1,841.10
Rate for Payer: Medical Mutual Of Ohio HMO	$1,776.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,598.51
Rate for Payer: Molina Healthcare Benefit Exchange	$649.80
Rate for Payer: Ohio Health Choice Commercial	$1,906.08
Rate for Payer: Ohio Health Group HMO	$1,624.50
Rate for Payer: Ohio Health Group PPO Differential	$433.20
Rate for Payer: Ohio Health Group PPO No Differential	$281.58
Rate for Payer: Ohio Health Group PPO SOMC Employees	$671.46
Rate for Payer: PHCS Commercial	$2,079.36
Rate for Payer: United Healthcare All Payer	$1,906.08

Know your out-of-pocket cost for care.

All Charges