Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

INJECTION HIP ARTHROGRAPHY(T

Facility

$1,278.00

Service Code	HCPCS 27093
Hospital Charge Code	761T0776
Hospital Revenue Code	761
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$1,226.88
Rate for Payer: Aetna Commercial	$984.06
Rate for Payer: Anthem POS/PPO/Traditional	$996.84
Rate for Payer: Cash Price	$639.00
Rate for Payer: Cigna Commercial	$1,060.74
Rate for Payer: First Health Commercial	$1,214.10
Rate for Payer: Humana Commercial	$1,086.30
Rate for Payer: Medical Mutual Of Ohio HMO	$1,047.96
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$943.16
Rate for Payer: Molina Healthcare Benefit Exchange	$383.40
Rate for Payer: Ohio Health Choice Commercial	$1,124.64
Rate for Payer: Ohio Health Group HMO	$958.50
Rate for Payer: Ohio Health Group PPO Differential	$1,022.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,111.86
Rate for Payer: Ohio Health Group PPO SOMC Employees	$881.82
Rate for Payer: PHCS Commercial	$1,226.88
Rate for Payer: United Healthcare All Payer	$1,124.64

INJECTION HIP ARTHROGRAPHY(T

Facility

$1,278.00

Service Code	HCPCS 27093
Hospital Charge Code	761T0776
Hospital Revenue Code	761
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$1,226.88
Rate for Payer: Aetna Commercial	$984.06
Rate for Payer: Anthem Medicaid	$439.50
Rate for Payer: Anthem POS/PPO/Traditional	$996.84
Rate for Payer: Cash Price	$639.00
Rate for Payer: Cigna Commercial	$1,060.74
Rate for Payer: First Health Commercial	$1,214.10
Rate for Payer: Humana Commercial	$1,086.30
Rate for Payer: Humana KY Medicaid	$439.50
Rate for Payer: Kentucky WC Medicaid	$443.98
Rate for Payer: Medical Mutual Of Ohio HMO	$1,047.96
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$943.16
Rate for Payer: Molina Healthcare Benefit Exchange	$383.40
Rate for Payer: Molina Healthcare Medicaid	$448.32
Rate for Payer: Ohio Health Choice Commercial	$1,124.64
Rate for Payer: Ohio Health Group HMO	$958.50
Rate for Payer: Ohio Health Group PPO Differential	$1,022.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,111.86
Rate for Payer: Ohio Health Group PPO SOMC Employees	$881.82
Rate for Payer: PHCS Commercial	$1,226.88
Rate for Payer: United Healthcare All Payer	$1,124.64

INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG

Facility

$0.45

Service Code	CPT J1885
Hospital Revenue Code	360
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.45
Rate for Payer: Anthem Medicare Advantage/PPO	$0.32
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$0.45
Rate for Payer: CareSource Just4Me Medicare	$0.43
Rate for Payer: Humana Medicare Advantage	$0.32
Rate for Payer: Molina Healthcare Benefit Exchange	$0.38

INJECTION KNEE ARTHROGRAPHY

Facility

$240.00

Service Code	HCPCS 27369
Hospital Charge Code	76100827
Hospital Revenue Code	761
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna Commercial	$184.80
Rate for Payer: Anthem POS/PPO/Traditional	$187.20
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna Commercial	$199.20
Rate for Payer: First Health Commercial	$228.00
Rate for Payer: Humana Commercial	$204.00
Rate for Payer: Medical Mutual Of Ohio HMO	$196.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$177.12
Rate for Payer: Molina Healthcare Benefit Exchange	$72.00
Rate for Payer: Ohio Health Choice Commercial	$211.20
Rate for Payer: Ohio Health Group HMO	$180.00
Rate for Payer: Ohio Health Group PPO Differential	$192.00
Rate for Payer: Ohio Health Group PPO No Differential	$208.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$165.60
Rate for Payer: PHCS Commercial	$230.40
Rate for Payer: United Healthcare All Payer	$211.20

INJECTION KNEE ARTHROGRAPHY

Professional

Both

$240.00

Service Code	HCPCS 27369
Hospital Charge Code	76100827
Hospital Revenue Code	761
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$257.44
Rate for Payer: Ambetter Exchange	$37.97
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$33.00
Rate for Payer: Anthem Medicaid	$108.58
Rate for Payer: Buckeye Individual/Medicaid	$37.97
Rate for Payer: Buckeye Medicare Advantage	$37.97
Rate for Payer: CareSource Just4Me Medicare	$45.56
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna Commercial	$257.44
Rate for Payer: Humana Medicaid	$108.58
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$54.99
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$37.97
Rate for Payer: Molina Healthcare Benefit Exchange	$37.97
Rate for Payer: Molina Healthcare CHIP/Medicaid	$110.75
Rate for Payer: Molina Healthcare Passport	$108.58
Rate for Payer: Multiplan PHCS	$144.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$49.36
Rate for Payer: UHCCP Medicaid	$34.65
Rate for Payer: Wellcare CHIP/Medicaid	$109.67
Rate for Payer: Wellcare Medicare Advantage	$37.97

INJECTION KNEE ARTHROGRAPHY

Facility

$240.00

Service Code	HCPCS 27369
Hospital Charge Code	76100827
Hospital Revenue Code	761
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna Commercial	$184.80
Rate for Payer: Anthem Medicaid	$82.54
Rate for Payer: Anthem POS/PPO/Traditional	$187.20
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna Commercial	$199.20
Rate for Payer: First Health Commercial	$228.00
Rate for Payer: Humana Commercial	$204.00
Rate for Payer: Humana KY Medicaid	$82.54
Rate for Payer: Kentucky WC Medicaid	$83.38
Rate for Payer: Medical Mutual Of Ohio HMO	$196.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$177.12
Rate for Payer: Molina Healthcare Benefit Exchange	$72.00
Rate for Payer: Molina Healthcare Medicaid	$84.19
Rate for Payer: Ohio Health Choice Commercial	$211.20
Rate for Payer: Ohio Health Group HMO	$180.00
Rate for Payer: Ohio Health Group PPO Differential	$192.00
Rate for Payer: Ohio Health Group PPO No Differential	$208.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$165.60
Rate for Payer: PHCS Commercial	$230.40
Rate for Payer: United Healthcare All Payer	$211.20

INJECTION KNEE ARTHROGRAPHY(P

Professional

Both

$240.00

Service Code	HCPCS 27369
Hospital Charge Code	761P0827
Hospital Revenue Code	761
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$257.44
Rate for Payer: Ambetter Exchange	$37.97
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$33.00
Rate for Payer: Anthem Medicaid	$108.58
Rate for Payer: Buckeye Individual/Medicaid	$37.97
Rate for Payer: Buckeye Medicare Advantage	$37.97
Rate for Payer: CareSource Just4Me Medicare	$45.56
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna Commercial	$257.44
Rate for Payer: Humana Medicaid	$108.58
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$54.99
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$37.97
Rate for Payer: Molina Healthcare Benefit Exchange	$37.97
Rate for Payer: Molina Healthcare CHIP/Medicaid	$110.75
Rate for Payer: Molina Healthcare Passport	$108.58
Rate for Payer: Multiplan PHCS	$144.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$49.36
Rate for Payer: UHCCP Medicaid	$34.65
Rate for Payer: Wellcare CHIP/Medicaid	$109.67
Rate for Payer: Wellcare Medicare Advantage	$37.97

INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY

Facility

$895.82

Service Code	CPT G0260
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$1,151.65

Service Code	CPT 64417
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$1,151.65

Service Code	CPT 64415
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$895.82

Service Code	CPT 64447
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$895.82

Service Code	CPT 64454
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE

Facility

$381.85

Service Code	CPT 64405
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

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,151.65

Service Code	CPT 64421
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL

Facility

$895.82

Service Code	CPT 64420
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH

Facility

$895.82

Service Code	CPT 64450
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE

Facility

$895.82

Service Code	CPT 64418
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

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

Facility

$1,151.65

Service Code	CPT 64479
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

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

Facility

$1,151.65

Service Code	CPT 64483
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

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

$1,151.65

Service Code	CPT 64490
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

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

$1,151.65

Service Code	CPT 64493
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

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

$895.82

Service Code	CPT 62321
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

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

$895.82

Service Code	CPT 62323
Hospital Revenue Code	360
Min. Negotiated Rate	$639.87
Max. Negotiated Rate	$895.82
Rate for Payer: Anthem Medicare Advantage/PPO	$639.87
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$895.82
Rate for Payer: CareSource Just4Me Medicare	$863.82
Rate for Payer: Humana Medicare Advantage	$639.87
Rate for Payer: Molina Healthcare Benefit Exchange	$767.84

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

$1,151.65

Service Code	CPT 62322
Hospital Revenue Code	360
Min. Negotiated Rate	$822.61
Max. Negotiated Rate	$1,151.65
Rate for Payer: Anthem Medicare Advantage/PPO	$822.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,151.65
Rate for Payer: CareSource Just4Me Medicare	$1,110.52
Rate for Payer: Humana Medicare Advantage	$822.61
Rate for Payer: Molina Healthcare Benefit Exchange	$987.13

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

Facility

$381.85

Service Code	CPT 20552
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

Know your out-of-pocket cost for care.

All Charges